Pre-registration of a learner

Journée d’étude du Centre Hospitalier Georges MAZURELLE : « clinique de l’angoisse » - the November 25, 2022

Bonjour, merci pour votre intérêt à nos formations. Vous pouvez vous pré-inscrire à la formation grâce à ce formulaire. Nous reviendrons vers vous par la suite. Vous pouvez laisser un message complémentaire dans la partie 'Notes libres'.

General information

Learner's photo

JPG, PNG or WebP, ≤ 500Ko

Honorific

First name*

Last name* Email* Date of birth*

Birth name

Nationality

City of birth

Postcode of place of birth

Address*

Postcode*

City*

Country

Phone

Language in the Learners' Portal

Status

Company

Profession*

Company name

VAT number

Company registration number

DPC fields

ADELI NO.

RPPS NO.*

Main exercise (> 50%)*

Other

Free notes

Information for funding agencies

Social security number

Fields marked with * are mandatory.

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