American University of Beirut Medical Center Student Application

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.


Office Use Only: Receipt No: ____________________ Amount: ________________ Date: _____________
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.