1. General InformationAcademic Title*First Name*Last Name*Department*Institution*Address*Town/City*Postal/ZIP Code*Country*Mobile Phone*E-mail*Passport Number*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.AffiliationsPlease 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.2. AccommodationA maximum of three (3) room/nights will be providedCheck In Date* DD MM YYYY Check Out Date* DD MM YYYY 3. Social EventsSocial Events* Welcome Cocktail - Friday 26 March 2021 Social Dinner - Saturday 27 March 2021 4. Special RequirementsDietary NeedsAccess Requirements5. Privacy and Treatment of Personal DataConsent* I have read the Privacy Policy and consent to the use of my personal data for the purposes specified therein.CAPTCHA
