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Personal details and nationality
Title *
Name * Last name *
Gender * Date of birth *  (dd/mm/yyyy)
Country of birth *
Province/State *
Place of Birth
Place of Birth *
Fiscal Code (or any code that allows you to identify yourself on an invoice) *
Tax code
(or any other type of ID) assigned by the State in which you are established, domiciled or resident
V.A.T. (Value Added Tax)
Residence or Contact details
Country of residence *
Province/State *
Province/State
City *
City *
Address *
Zip code *
Telephone (+XXXXXX) *
Telephone (+XXXXXX)
Fax Mobile (+XXXXXX)
Email *
Profession and Specialization
I ask the awarding of Italian CME credits
Occupational status *
Profession *
Specialization *
CLICK HERE TO ADD THIS SPECIALIZATION
Other personal information
OTHER (specify in the notes on the following page)
FISHETARIAN
GLUTEN FREE
NO LATTOSIO
VEGAN
VEGETARIAN

* Required
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