9/8/2011

IEA - Online Application

CONTACT US IEA COURSES Thursday, 08 September 2011

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Online Application

Online Application
APPLICATION FORM
Deadline for receipt of applications: November 1, 2011 Please answer each question clearly and completely. All relevant information should be included on this form. PLEASE COMPLETE IN ENGLISH.

* required fields
Prefix (*) First Name (*) Last Name (*) Professional address Address (*) Mailing address (if different) Address

City (*) State / Province (*) Country (*) Zip / Postal Code (*) Telephone (*) Cellular/Mobile Fax Email (*) Place of Birth Nationality (*) Date of Birth yr / mth / day Sex (*) Male Female

City State / Province Country Zip / Postal Code

EDUCATION AND EXPERIENCE

Qualifications (start with most recent) (*) Institution name and city From To Field of study Qualification

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IEA - Online Application

Present post Years of service (*): From Title of your post (*) Name and full address of the Institution or Agency, which employs you (if different from above) To

Tel Fax

List of relevant publications:

Present research experience and activities, including any previous epidemiology courses attended:

How do you think this course would benefit your future professional activities? (*)

OTHER QUESTIONS
1. Have you any experience of working with computers? (*) Yes No If yes, please specify the computer packages you are familiar with

2. Do you have a sufficient knowledge of spoken English? (*) 3. Are you a member of the IEA? (*) Yes No

Yes

No

4. What is your accommodation preference? (*) single room at US $1,000 sharing a room with another student at US $800 do not require accommodation - course fee only - US $500 Please note that the course is heavily subsidized and no discounts will be given.

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I understand that, if I am accepted, I must participate in the complete course, from 9 a.m. Monday, May 7th to 1 p.m. Friday, May 18th, 2012. I shall be responsible for the costs of my travel. My course fees will cover the costs of accommodation, breakfast and lunch during my stay in Lima, Peru. (*)

Submit

CONTACT US
Course Secretariat IS Event Solutions T. 450.550.3488 x114 F. 514.227.5083 Email

QUICK LINKS

Keep me Posted!

World Congress First Name(*) Last Name(*) E-Mail(*)

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