Faculty Form

General Information
Academic Title*
First Name*
Last Name*
Department*
Institution*
Address*
Town/City*
Postal/ZIP Code*
Country*
Mobile Phone*
E-mail*
Passport Number*
I confirm my attendance*
- Virtually
- In-person
I hereby declare that*
- I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device organization. Speakers who have no involvement with industry should inform the audience that they cannot identify any conflict of interest.
- I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device organization. Complete the section below as it applies to you during the past two years.
Affiliations
Please indicate the commercial organization(s) with which you have/had affiliations, and briefly explain what connection you have/had with the organization. You must disclose this information to the audience.
Accommodation
A maximum of three (3) room/nights will be provided
Check In Date*

DD
MM
YYYY
Check Out Date*

DD
MM
YYYY
Social Events
Social Events*
- Welcome Cocktail - Friday 26 March 2021
- Social Dinner - Saturday 27 March 2021
Special Requirements
Dietary Needs
Access Requirements
Privacy and Treatment of Personal Data
Consent*
I have read the Privacy Policy and consent to the use of my personal data for the purposes specified therein.
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General Information