PRE-REGISTRATION FORM FOR THE ONSITE COURSES 2020 1 Your informations2 Application The information collected on this form is recorded in a data file by the Institute of Image-Guided Surgery (IHU Strasbourg) for the selection and the recruitment candidates. They are kept during 1 year and are intended for the B.E.S.T. team for the organization of the onsite course. According to the law "Informatique et Libertés" n°78-17 of January 6, 1978, information about you is to B.E.S.T. Team controller.You are*Prof.Dr.Mr.MrsName* First Last Username*Username on B.E.S.T. Innovation websitePhone*Please provide the area codeEmail* Enter Email Confirm Email Professional profile*InstitutionHospitalLaboratoryIndustryUniversityotherContact address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country You are?*a doctor, a surgeon ...an engineerAre you currently a student?*YesNoIf yes, please upload in .pdf format your student ID Card and Passeport*The maximum size limit for your documents should not be greater than 2MB! If you have difficulty to reduce the weight of your file, you can use tools on-line as smallpdf.com. Drop files here or Accepted file types: pdf, jpeg. You wish to apply to the BEST On-site course 2019:*In Taichung, Taiwan (IRCAD Taiwan) From July 20th, 2020 to July 24th, 2020In Strasbourg, France (IRCAD France) August 31st to September 4th, 2020In Barretos, Brazil (IRCAD-AMERICA LATINA) December 14th, 2020 to December 19th, 2020To date, you validated which of these courses:*You must have completed the first two on-line modules and successfully passed the related evaluations.The final deadline is on June 14th, 2020 for Taiwan and June 5th for Strasbourg and November 1st for Barretos. 1 - Basic of Laparoscopy 2 - Laparoscopic Procedures 3 - MIS Technologies 4 - Biomedical Engineering 5 - Entrepreneurship Please upload your CV and Cover letter in .pdf format*The maximum size limit for your documents should not be greater than 2MB! If you have difficulty to reduce the weight of your file, you can use tools on-line as smallpdf.com. Drop files here or Accepted file types: pdf, jpeg. Terms and conditions* By submitting this form you consent to the processing of their data. For more informations read our legal notices PhoneThis field is for validation purposes and should be left unchanged.