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Pre- Registration Form

First Name
Family Name/Other Name
Qualification
Sex
Male Female
Address
City
Zip
State
Country
Phone
Fax
Email
Name of the Event you are Registering
Indicate the venue where you will attend the event.(please name the venue from the one's where the event will take place)
I want the UAB certificate

(Please note that the foundation will facilitate UAB CME Certificate only in venues where UAB faculty is part of the workshop/course faculty)

Yes No
Any additional information you want to give

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