American University of Beirut Medical Center Student Application

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American University of Beirut Medical Center

Student Application

Applicant Information


Date of birth:



Employment Information

Current work address:
Hospital name/Clinic:






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


I authorize the verification of the information provided on this form as to my credit and employment.

Signature of applicant:


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.

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