Pre-registration of a learner

E-learning - La Douleur - Saison 1 : Types, Composantes, Fonctions et Evaluation - from October 17, 2022 to March 15, 2023

Vous pouvez préinscrire un apprenant à la formation grâce à ce formulaire. Merci de rentrer un maximum d'informations pour simplifier le travail d'enregistrement. 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

County of birth

Postcode of place of birth

Address*

Postcode*

City*

Country

Phone*

Secondary 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%)*

National guidelines

Other

Free notes

Information for funding agencies

Social security number

Socio-professional category

Nature of the employment contract

Gross hourly wage

Disabled worker recognition

Fields marked with * are mandatory.

The data collected in this form is processed by AB+ Formation santé in order to manage your registration on the site. To find out more about the management of your personal data and to exercise your rights, we invite you to read our privacy policy