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Phone
Phone
John Doe

Registration form
Title before name:
First name:
Surname:
Title after the name:
Phone number including country code:
+420 777 111 111
E-mail:
Hospital:
Department:
Role in hospital:
Street / house No:
Town:
Postal code:
Country:
Type of the payer:
Person / hospital:
Street / house No:
Town / City
Country:
Postcode:
VAT No:
I agree with processing of my personal data by Faculty of Medicine Hradec Kralove, Czech Republic/T.R.I s.r.o. Czech Republic according to the rule No 1102019 of Data Protection Act
I agree with processing of my personal data by third parties (medical device vendor/pharmaceutical company) for the purpose of marketing activities
Registration form
Total to be paid: