Request for an Endo-Trainer™-Event

Please fill-in the following boxes as completely as possible. Due to the limited number of workshops for 2010, we ask you to apply early.

Sender:  , email address:
Clinical contact person
& phone number:
Venue:
Address of institution:
Preferred date:
Standard package: 2 Endo-Trainer™ models per day and event
Cost-split: DIRECT CHARGES (0,60€/km; applicable hotel & rental car) normally borne by clinical organizer; EVENT COSTS assumed by partner or external funds
Direct charges covered by: Clinical organizer
ECE partner
Event costs covered by: DGCH
Fujinon
Erbe
Mediglobe
External funds
Contact person at Fujinon/Erbe/Mediglobe:
Invoice address:
Additional information:
Current schedule