***   Pharmaceutical SC: Medicines Shortages (II)  ***      ++++++++++++  (03-07 July-2017)   ++++++++++++
European Medicines Shortages Research Network - addressing supply problems to patients
                                                 (Medicines Shortages, CA15105)


                                                       REGISTRATION FORM:
                       Applicants from Countries & Institutions associated to CA15105


                    Please fill in this form using the same information on your COST profile!
                         If not registered yet in the COST network, then follow the link
                                              https://e-services.cost.eu/user/login/ 


ATTENTION: before submission, please save a "pdf" version of this e-form! then...                        
                        i) send it to the Portuguese Coordinator (mailto:jlmiranda@estgp.pt), and
                       ii) a confirmation procedure is foreseen!

                             DEADLINE: The registration will continue until the Action objectives,
                                                   the Training School goals be fulfilled (continuous submission).
                       
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Name (P1) *
 Complete name
Address (P2) *
Complete post address
Phone Number (P3) *
Complete phone number, with the country code
e-mail (P4) *
Reference e-mail for the COST platform
Nationality (P5) *
Nationality
Year of Birth (P6) *
(yyyy)
Gender (P7) *
(M/F)
Identification document (ID1) *
Document for identification
Identification document (ID2) *
The code-number of the document selected
Country/Institution in the COST Action "Medicines Shortages" (A1) *
Your country and institution
Current situation at local institution (A2) *
Check the box related with the program you are participating
Required
Field of study/research (A3) *
Check the box related with your field of study
Academic Degrees (A4) *
... with score and range (ex.: MSc. in Phamaceutics, 19 values in 1-20 scale)
Researching Motivation *
Include a motivation text (< 2000 chars); please add research items/results that could be of interest.
Verification *
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