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 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.

Speaker Profile

Short Professional Biography*

Speaker Photo*

Please submit a head shot photo to accompany your bio. The minimum dimension of your photo should be 500x500 pixel.

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.

Terms of Participation

Terms 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

We kindly ask you to fill-in the following Faculty Form to confirm your attendance possibly by January 10th, 2021.

General Information

Speaker Profile

Privacy and Treatment of Personal Data

Terms of Participation

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