EACTM 2020 Application Form
First Name *
Your answer
Last Name *
Your answer
Degree *
Your answer
Degree Completion *
Required
Medical Specialty *
Your answer
Address *
Your answer
City *
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State
Your answer
Country *
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Date of Birth *
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DD
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YYYY
Office Phone
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Home Phone
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Mobile Phone
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Fax Number
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Primary Email Address *
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Secondary Email Address
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Organization/Institution you are associated with:
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Do you qualify for a reduced rate?
Clinicians living and working in low/lower middle income countries as defined by the World Bank - http://data.worldbank.org/about/country-and-lending-groups
Brief statement *
Submit a brief statement describing your background in tropical medicine and/or infectious disease, as well as a paragraph about why you think this course will be of value to you (maximum 500 words):
Your answer
Did you submit your resume and/or curriculum vitae? *
Email your resume and/or curriculum vitae to radic011@umn.edu.
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