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asmiua presentation registration form

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PRESENTATION REGISTRATION FORM Presentation (choose one √): □ Poster presentation □ Video presentation Author(s): No Title Urologist/ Urology Resident First Name Surname Institution Presenter : Address : Email : Phone Number : Presentation Title : Hereby we stated that presentation content (video/poster) submitted is original, and we are responsible for the material contained in the presentation. We give full permission to the organizing committee of the 37 th ASMIUA to use our presentation for professional purpose. .................. , .......................... 2014 (signed here) (Participant)

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ASMIUA, registration form

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Page 1: ASMIUA Presentation Registration Form

PRESENTATION REGISTRATION FORM

Presentation (choose one √):

□ Poster presentation

□ Video presentation

Author(s):

No Title

Urologist/ Urology Resident First Name Surname Institution

Presenter :

Address :

Email :

Phone Number :

Presentation Title :

Hereby we stated that presentation content (video/poster) submitted is original, and we are responsible

for the material contained in the presentation. We give full permission to the organizing committee of

the 37th ASMIUA to use our presentation for professional purpose.

.................. , .......................... 2014

(signed here)

(Participant)

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