SLACOM - Sociedad Latinoamericana y del Caribe de Oncología Médica
 
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SLACOM - Registration Card
Last name and Name:  
Profession:   Specialty:
 
Address:  
City:   Zip Code:
 
Province:   Country:
 
Phone:   Mobile:
 
E-mail:  
Institution/Organization:  
Address:  
City:   Zip Code:
 
Province:   Country:
 
Phone:   Fax:
 
Alternative Phone:  
E-mail:  
Specialist degree:   Date:
SI NO   (dd/mm/aaaa)
Specialty:   Granted by:
 
Recertification:   Date:
SI NO   (dd/mm/aaaa)
Granted by:  
Member of:  
ASCO: YES NO ESMO: YES NO SMeO: YES NO
SBOC: SI NO SBO: SI NO
Other (specify):    

PRESENTED BY:

Member 1:   Signature:
 
Member 2:   Signature:
 

I will attach my curriculum vitae via e-mail/diskette (in Word format).

Date:   Signature:
(dd/mm/aaaa)  



 
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