Educational Grant Request

Personal Details:

2. Please provide us with your full name (as stated in your passport): *This question is required.

First name(s):
Last name:

3. CIRSE ID

if you do not have a CIRSE ID please register to myCIRSE *This question is required. This question requires a valid number format.

Please specify your profession *This question is required.

5. Please provide us with information on your hospital / institution *This question is required.

Hospital / Institution
City

6. Please provide us with information on your Head of Department at your hospital *This question is required.

Title:
First name(s):
Last name:
Position:

7. Date of Birth *This question is required. Please use the DD/MM/YYYY date format (e.g. 22/12/1980) This question requires a valid date format of DD/MM/YYYY.

calendar

Contact Information:

Email *This question is required. This question requires a valid email address.

Confirm Email *This question is required. This question requires a valid email address.

8. Country

Netherlands industry regulation

Please note that due to industry regulations in the Netherlands, the HCP may only receive a maximum of €500 in
sponsorship per event, with a maximum of €1500 in one year. Alternatively, the HCP can agree to pay 50% of the
sponsorship amount per event. *This question is required.

I have read and understood this clause

Please indicate your RPPS number

9. Telephone Number

Country code *This question is required.

Please indicate the country code in the format +123 *This question is required. This question requires a valid number format.

Phone number *This question is required. This question requires a valid number format.

10. I am interested in participating in the below events: *This question is required.

ICCIR 2020 - Poertschach, June 4-6
CIRSE 2020 - Munich, September 12-16
ECIO 2020 - Nice, November 2 - 5
ET 2020 - Vienna, December 16 - 19

11. Please provide us with additional information on why you should be awarded an Educational Grant: *This question is required.

12. Personal Data & Consent terms *This question is required.

I agree to the Personal Data & Consent terms