Registrationform SMPE/e course 'PPMT 2024'

Required fields are marked with an asterisk (*)

Personal data

Surname (family name)*

Insertion (e.g. 'van' or 'van der')

Firstname*

Initials*

Title

Gender*

Date of birth (for certificate): e.g. July 1, 1994*

Place of birth (for certificate)*

Telephone number (preferably mobile in case of last minute changes in programme)*

Contact data

E-mail*

Street and number of private address*

Postal code + city of private address (e.g. 5600 MB Eindhoven)*

Name hospital/company/institution*

Street and housenumber from hospital/company/institution (no postbox)*

Postalcode and + city of hospital/company/institution*

Position*

Department*

If other, please write down your field of training or work

Courseregistration

Coursedates:September 16-17-18, September 30-October 1 + *Comeback Day on December 2, 2024.
*All Options are with Comeback Day
I want to subscribe for:

5-days course*

September 16-17-18, September 30-October 1 + *Comeback Day on December 2, 2024

Block 1: 3-days course*

September 16-17-18 + *Comeback Day on December 2, 2024

Block 2: 2-days course*

September 30-October 1 + *Comeback Day on December 2, 2024

Billing

Send the bill to*

Homeaddress

Hospital/company/institution

TU/e (I am a CI/QME/PhD trainee)

Costcenter/Projectnumber/Activitynumer/Ordernumber/reference number (with homeaddress-not applicable) TU/e trainees: please also fill in your project or activitynumbers. Thank You!*

Dietwishes

Course expectations

What do I expect from this course (day)?*

Attention: If you have not received a confirmation of registration by email please check your SPAM folder and notify smpee@tue.nl directly. Thank you!

Don't fill this field!