We kindly ask you to fill-in the following Faculty Form to confirm your attendance possibly by January 10th, 2021. General InformationAcademic Title*First Name*Last Name*Department*Institution*Address*Town/City*Postal/ZIP Code*Country*Mobile Phone*E-mail*Passport NumberI 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.Speaker ProfileShort Professional Biography*Speaker Photo*Please submit a head shot photo to accompany your bio. The minimum dimension of your photo should be 500x500 pixel.Accepted file types: jpeg, jpg, png, pdf.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.Terms of ParticipationTerms of Participation*The personal data you provide will be used to register you for this event. By completing this registration form, you accept the Terms & Conditions and the Data Collection Consent for 6Connex.Yes, I understand that my information will be processed and shared with the aforementioned parties in order to process my registration.No, I do not want my information processed and shared with the aforementioned parties and understand I will not be registered.CAPTCHA
