Course Request Form

Course Director Name *

First Name

Last Name

Course Director Phone Number *

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Course Date *

MM

DD

YYYY

Emergency Surgery Textbook Shipping Address *

The ESC textbook will be shipped and arrive approximately 15 days prior to the event. The books are being shipped directly from the publisher, Wolters Kluwer. Please include as much detail as possible for shipping. Staff will contact you to obtain a final count on the number of books needed prior to shipping.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Course Information *

(Please check each box to express your understanding of each statement)

I understand that I am responsible for ordering and paying for the ES Textbooks

I understand that I am responsible for travel, hotel, and food for the course faculty

I understand that I am responsible for all costs related to venue including AV, room rental cost, and food

I understand there is a fee to host the course (€50/per registrant) and I will pay it within 30 days after receiving the invoice. I understand the textbooks will not be shipped until the fee is paid.

I understand that I am required to fill out a final report and submit it within 30 days after the course is completed

I understand that I must fill out an evaluation form on the course

Date: *

MM

DD

YYYY