American University of Beirut Medical Center Student Application



Yüklə 292,48 Kb.
tarix14.12.2016
ölçüsü292,48 Kb.

atcn logo

American University of Beirut Medical Center


Student Application

Applicant Information


Name:


Date of birth:

Phone:

Email:

Employment Information


Current work address:
Hospital name/Clinic:

Building:

Street:

City:

Country:



Position:

If PYG specify your rank

Specialty (one or more):

□ Resident □ Intern □ General Surgery □ Vascular Surgery □ Plastic Surgery □ Cardio-thoracic Surgery □ Orthopedic □ Neurosurgery □ ENT

□ Emergency Medicine □ Other: ____________________________________

General information


Graduation date (if applicable)




LOP/ONL/licensure number:




Special training:

ATLS/ATCN information


Registration date:

Course date:

Course: □ ATLS® Student course

□ATLS® Instructor course □ATCN® Instructor Course

□ ATCN® Student course

□ATLS® Auditor □ATLS® Student Refresher course

ATLS ID number (if applicable)

□ATCN® Student Refresher course

Signatures


I authorize the verification of the information provided on this form as to my credit and employment.

Signature of applicant:

Date:

Advanced Trauma Life Support® Lebanon Chapter

Application Form



Please write your name in CAPITAL letters as you want it to appear in your certificate.


Office Use Only: Receipt No: ____________________ Amount: ________________ Date: _____________
Please note that your registration will only be confirmed upon receipt of payment. Cancellation or rebooking requires a minimum of one month notice. No refund will be given for cancellation/postponements made less than one month prior to the course date, or failure to attend the course.

Yüklə 292,48 Kb.

Dostları ilə paylaş:




Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©www.azkurs.org 2020
rəhbərliyinə müraciət

    Ana səhifə