sg-az-321_registration

REGISTRATION
Please complete the form below to register your interest in attending the webinar.
(*) Mandatory field; data may be required for CME application in your country.

Country: *

country other *

First name as in ID *

Last name (Surname) *

Email address *

Hospital / Clinic *

MCI Registration Number *

Contact Number *

License Number *

MRC Number *

Mobile Number *

for CME accreditation

NRIC Number *

Mobile Number *

for CME accreditation

MMC Number *

IDI Membership Number

Contact Number *

License Number

MCHK Number *

Contact Number *

College membership *

Full Name in Chinese *

IC Number *

Society member number *

(for TSPCCM)

Contact Number *

First Name *

Middle Name *

Last Name *

Professional License No *

Contact Number *

Specialty: *

specialty other *

I would like to attend

I would like to attend Webinar 5 only.
I would like to attend all Healthy Lung Masterclass Asia Webinars.

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I confirm *

I confirm that I am a Healthcare Professional and I consent for my data to be collected by the meeting organizer for use in this meeting only.

(OPTIONAL) I would

(OPTIONAL) I would like to be contacted for similar events in the future and consent to the processing of my data by AstraZeneca Asia as set forth in the Privacy Policy.