CX Grant 2018 Application Form – JOTEC 2017-12-06T10:58:26+00:00

 

The CX Symposium organiser, BIBA Medical, is an Ethical MedTech Trusted Partner, meaning we’re committed to the ethical standards set out in the MedTech Europe Code.

CX 2018 Educational Grant Application Form – Jotec

  • Requests will be reviewed by a Grants Review Panel and grants will be allocated on a first come first served basis
  • Please complete all sections as failure to do so could result in a rejection
  • Completed forms should be submitted no later than 1700 GMT on 23rd Jan 2018
  • Generally applicants will be informed within five working days if their application has been accepted
  • The grant will cover:–Full CX registration (access-all-areas)
    Up to 3 hotel nights (single occupancy, including bed and breakfast and VAT). Stays of four hotel nights will be provided when justified appropriately due to travel requirements. No accommodation will be given to HCPs from the London area.
    Travel reimbursement (economy flight/train up to the value of £500 for Europe, or £700 for the MENA region)
  • Selected applicants must register themselves using an online code provided
  • We request that successful applicants complete a short feedback questionnaire during or after the event
  • The CX Travel team will book your travel and accommodation
  • Please select your country in the drop-down menu. The number of available participant grants for each region is limited, therefore countries may not be listed when no more applications can be considered.
  • IMPORTANT: The CX Travel Team will require a credit card from you as a guarantee of your travel and accommodation booking.
  • Your place at CX 2018 will not be guaranteed until you’ve provided the credit card guarantee. 

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?

Please provide the company name

Please provide the institution name

Please provide the institution/medical association/foundation name

Please specify "Other" details

Please let us know how you will benefit from attending CX:

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

By submitting this form, I certify that all information provided in my application is true and correct to the best of my knowledge (please tick).

I Confirm

We will add you to the mailing list for information on the Charing Cross Symposium and our newsletter(s) targeted at your speciality. If you do not wish to receive newsletters from us, please select *Yes - CX only or *No
Yes (All)Yes CX Symposium onlyNo (All)