Scheda di Iscrizione al corso STRATEGIE TERAPEUTICHE IN EPILESSIA Hotel Gli Dei - Pozzuoli (Na) , 15 maggio 2015 Si prega di inviare per fax o email a: FORMA Communications s.r.l. Via Chiaia, 149/E – 80121 Napoli Italy Fax +39 081 714 59 54 Email: [email protected] □ Prof □ Dr □ Sig Cognome ______________________________________________________________________________ Nome _______________________________________________________________________________ Data di nascita _ _ /_ _ /_ _ _ _ (gg/mm/aaaa ) □M □ F Istituto_________________________________________________________________________________ Dipartimento___________________________________________________________________________ Indirizzo _______________________________________________________________________________ Codice postale __________________________________________________________________________ ______ Città __________________________________________________________________________________ Tel. _______________________________________Cell _______________________________________ E-mail:_________________________________________________________________________________ Data _________________________ Firma ___________________________
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