Registration Form

Please fill in this form, click on File at the top of your browser & then

click on print from the file menu to print this page and mail it with your

payment to PO Box 4848, Fujairah OR Fax 09 222 9077.

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Please provide the following contact information:

Title

Name

Hospital

Address

Address (cont.)

City

Zip/Postal Code

Country

Work Phone

FAX

Mobile Phone

E-mail

Age

Designation:

Specialty:

Year of Graduation:

Post-Graduate Qualifications:

Year of Post-Graduation:

Date of any ATLS provider course attended along with the registration number:

Date of any ATLS instructor course attended along with the registration number:

Are you interested in and available for the Instructor course?

(Please note that you must successfully complete the Student Course

and be identified as having instructor potential to attend the Instructor Course)

Yes No

Are you paying by

We would prefer that the fees is deposited into Abu Dhabi Commercial Bank

A/C No: 2335 2802 0001 in the name of "Trauma Committee" . No form will be

accepted without full payment. Please enter the details of your payment in the space below.