American University of Beirut Medical Center Advanced Trauma Life Support® Lebanon Chapter Application Form Please write your name in CAPITAL letters as you want it to appear in your certificate. Please note that your registration will only be confirmed upon receipt of payment. Cancellation or rebooking requires a minimum of one month notice. No refund will be given for cancellation/postponements made less than one month prior to the course date, or failure to attend the course. Student Application Applicant Information Name: Date of birth: Phone: Email: Employment Information Current work address: Hospital name/Clinic: Building: Street: City: Country: Position: Specialty (one or more): □ □ □ □ □ Resident Intern General Surgery Vascular Surgery Plastic Surgery □ □ □ □ Cardio-thoracic Surgery Orthopedic Neurosurgery ENT □ □ Emergency Medicine Other: ____________________________________ If PYG specify your rank General information Graduation date (if applicable) LOP/ONL/licensure number: Special training: ATLS/ATCN information Registration date: Course date: □ATLS® □ATCN® Instructor course Instructor □ ATLS® Student course Course: Course □ATLS® □ATLS® Auditor Student Refresher □ ATCN® Student course course □ATCN® Student Refresher course ATLS ID number (if applicable) Signatures I authorize the verification of the information provided on this form as to my credit and employment. Signature of applicant: Date:
American University of Beirut Medical Center Student Application Applicant Information Name: Date of birth: Phone: Email: Employment Information Current work address: Hospital name/Clinic: Building: Street: City: Country: Position: If PYG specify your rank Specialty (one or more): □ Resident □ Intern □ General Surgery □ Vascular Surgery □ Plastic Surgery □ Cardio-thoracic Surgery □ Orthopedic □ Neurosurgery □ ENT □ Emergency Medicine □ Other: ____________________________________ General information Graduation date (if applicable) LOP/ONL/licensure number: Special training: ATLS/ATCN information Registration date: Course date: Course: □ ATLS® Student course □ATLS® Instructor course □ATCN® Instructor Course □ ATCN® Student course □ATLS® Auditor □ATLS® Student Refresher course ATLS ID number (if applicable) □ATCN® Student Refresher course Signatures I authorize the verification of the information provided on this form as to my credit and employment. Signature of applicant: Date: Advanced Trauma Life Support® Lebanon Chapter Application Form Please write your name in CAPITAL letters as you want it to appear in your certificate. Please note that your registration will only be confirmed upon receipt of payment. Cancellation or rebooking requires a minimum of one month notice. No refund will be given for cancellation/postponements made less than one month prior to the course date, or failure to attend the course.
Student%20Application%20ATLS-%202015.docx