Grants Middle East | MLCTO Academy

Dr
Pr
None

Family name*

First name*

E-mail adress*

Cell phone number*

Cell phone number (only) Please indicate in front of your phone number, the country dialling code of your country.

Affiliated Medical Center*

Country*

City*

REGISTRATION

Profil*

Physician
Fellow
Paramedic

What do you perform in your daily practice ?*

Coronary angioplasty
Structural heart interventions
CRM
Peripheral angioplasty
Interventional radiology
Cardiac surgery

How many percutaneous coronary interventions are performed per year in your center?*

Do you have a CTO PCI program in your cath lab?*

Yes
No

How many CTO PCI have been performed during 2022 in your center?*

How many CTO PCI did you personally perform during 2022 ?*

How many CTO PCI do you consider performing this year?*

Have you already participated in the ML CTO Course (in Nice)?*

Yes
No

Have you applied for a grant to participate?*

Yes, but my application was not accepted
No, I registered by my own means

How have you heard about the ML CTO Middle East Course?*

Newsletter
Website (browser)
Social media
Industry
Peer
Other

Please indicate which industry and country ?

Other (please specify)*

What are the reasons why you want to attend this Course?*

ACCOMMODATION

Select the number of night(s) you would like to stay*

Night of October, 4th (October 4th to 5th, day before the congress)
Night of October 5th (October 5th to 6th)

This package includes a single room for two nights at the hotel. All the information concerning your hotel will passed on to you before the event.

Special accommodation requests

TRANSPORT

Airport and/or station tranfers will be handled by the organization. You will receive detailed information in your travel book few days before your departure by email.

Your flight will be in economic class, if you wish to travel in business class, it will be to your own charge.

Do you need a transportation booking?*

Yes
No

Departure city*

Departure date*

Departure time*

Morning
Afternoon
Evening

Return city (if it is not departure city)

Return date*

Return time*

Morning
Afternoon
Evening

Membership card type and number (airline, railroad company...)

Preferred Airline company

Upload your passport or ID Card*

Accepted file types: jpeg, jpg, png, pdf, gif, Max. file size: 128 MB.

Essential to book your travel. Thanks.

Special travel requests (aisle, window...)

SOCIAL PROGRAM

ML CTO DINNER (October 5th)*

Yes, I take part to the gala dinner
I will be accompanied by one person (60$)
No, I do not take part to the gala dinner

Email

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REGISTRATION

ACCOMMODATION

TRANSPORT

SOCIAL PROGRAM

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