CICE Diploma of Advanced Laparoscopy in Gynecology 2020
REQUEST FOR REGISTRATION to Diploma of Advanced Laparoscopy in Gynecology WITH European Certification - Level 1 "Bachelor" OR Level 2 “MIGS”

from Monday 7 to Friday 11 DECEMBER 2020

Place of course :
CICE
Bâtiment 3 C
28 Place Henri Dunant
TSA 50400 - 63001 Clermont-Ferrand Cedex 1
France

Your registration file (response to this form as well as the documents to be provided (see below)) must be returned complete BEFORE 1st NOVEMBER 2020.
After this date if your file is not complete your registration will not be considered.

We remind you that places are limited. We suggest that you return your file to us before the deadline because once we have received the 40 applications, the remaining applications will be on a waiting list.
Email address *
PERSONAL INFORMATIONS
NAME *
FIRST NAME *
Date of birth *
MM
/
DD
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YYYY
Your nationality *
Sex *
Personal Address *
Zip Code *
City *
Country *
Mobile *
Professional phone *
Email *
PRICE / 2020 with European Certification
- GYNECOLOGISTS, SURGEONS, RESIDENTS:
- Level 1 “BACHELOR” : 1 400 € / person
- Level 2 “MIGS” : 1 500 € / person
PAYMENT
By transfer bank when you will receive your confirmation
(bank transfer fees must be included in the supplement: amount of training fees + bank fees).
THEORETICAL & PRATICAL COURSES
BE CAREFUL : For this training, all the theoretical and practical courses, the session and the test for the European Certification will be distributed in English only (without translation), as well as the educational documents or other supports which will be given to you.
CANCELLATION
No postponement or cancellation can be taken into account, resulting in no refund
DOCUMENTS TO PROVIDE by email otherwise your file will not be considered complete and validated
(To send by email to secretariat@cice.fr)
- Photocopy (front and back) of the valid identity card or passport or individual civil status card or birth certificate less than 3 months old,
- Certificate of Gynecology resident or copy of the Diploma (Physician, Gynecologist, Surgeon and Surgeon Gynecologist),
RIGHTS TO IMAGE
I authorize the International Center for Endoscopic Surgery (CICE) to use and distribute, free of charge and non-exclusive, images (photos or films) representing me, clearly not blurred, taken during the internship. The aforementioned photographs and films are likely to be reproduced and broadcast: on our website www.cice.fr, on Cice supports, plates and other communication media- at Congresses, courses and all events in which the CICE is represented. *
I agree to send my contact details (email, telephone, postal address ...) to the company KARL STORZ, in order to be, if necessary, contacted again by the latter *
I confirm that I have never passed Level 1 "Bachelor" of European Certification *
I accept the registration conditions *
CONTACT
Mme Béatrice JAFFEUX
CICE – Bâtiment 3C
28, place Henri Dunant – BP 38 - 63001 CLERMONT-FERRAND Cedex 1 - FRANCE
Tél : +33(0)4 73 15 20 50 - E-mail : secretariat@cice.fr - Site : www.cice.fr
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