CX 2019 Grant Registration Form

Please register interest in a grant for CX 2019 by completing the form below before 1700 GMT on 4th January 2019

Please note that due to the high number of registrations we receive, we cannot respond to every submission. We will be in touch if we have grant funding available for your institution and country. The deadline for industry grant submissions is the 15th February, therefore we will let you know the outcome of your submission no later than this date.

If you have any queries please email cxsymposium@bibamedical.com

Title (required):

First Name (required):

Surname/Family Name (required):

Institution (required):

Job title (required):

Job Speciality (required):

Other speciality:

Address details

Address Line 1 (required):

Address Line 2:

City/Town (required):

County:

Country (required):

Identification number (RPPS for physicians, Semester for medical students):

Please Note: If your application is successful, any financial support towards your participation will be subject to the approval of the Mdeon Visa; this is a legal requirement and you will therefore be expected to provide additional information upon request of BIBA Medical. Failure to submit the required information will result in your application being rejected. I agree

Post code/Zip Code (required):

Email address (required):

Email address 2 (e.g. assistant / personal email address)*:

Telephone number (required):

Mobile/Cell number:

Have you ever attended CX before?
YesNo

If yes, how was your registration funded?
Self-fundedSupported by a companySupported by an institutionFacultyOther

Please provide the company name

Please provide the institution name

Please specify "Other"

Please let us know your main area of interest at the event:

Please let us know your secondary area of interest at the event:

Please let us know your third area of interest at the event:

We take your privacy seriously and will only use your personal information to administer your account and to provide the services required at the conference.

However, from time to time BIBA Medical and its partners would like to keep you up to date on relevant news, events and products. If you consent to us contacting you for this purpose, please let us know.

I am happy to receive emails from:

CX SymposiumVascular NewsVenous NewsInterventional News

We would also like to pass your details onto our Pavilion sponsors in order that they can gain a better understanding of the event’s audience. If you consent to us passing on your details for this purpose please tick to confirm:

I agreeI do not agree

By checking this box I confirm that I have read and agree to BIBA Medical’s terms and conditions and privacy policy

I confirm

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