KING ABDULAZIZ MEDICAL CITY - NATIONAL GUARD HEALTH AFFAIRS by 242e0MF

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									                       KING ABDULAZIZ MEDICAL CITY
                     NATIONAL GUARD HEALTH AFFAIRS
                  KING ABDULLAH INTERNATIONAL MEDICAL
                     RESEARCH CENTER-WR, KAIMRC-WR
               RESEARCH PROMOTION AND EDUCATION SECTION, RPES
                        : (02) 624-0000 x 24883 /  : 6123
                                Fax #: (920008668) 28203
                          Email: kaimrc-wr@ngha.med.sa

                                                                             NO:
                   COURSE REGISTRATION FORM
                                                                       Date: _________

 Personal Information: (Please write in capital letters)

                                     Male             Female

First Name



Middle Name



Last Name


Professional Title :_________________________________________________________
Badge No.    : _________________________________
Nationality:______________________                Saudi Council No.: ________________
Hospital     : _________________________________________________________________
Department: _________________________________ Mail Code: ______________________
P.O. Box     :_________________________________ City           :______________________
Postal Code:_________________________________ Country          :______________________


 Contact Numbers: (Please include telephone area codes if applicable)

Telephone    :_________________________________ Pager :__________________________

Fax Number: _________________________________ Mobile Phone:____________________
E-mail Address: _______________________________________________________________


 Course Details:

Course Title: _________________________________________________________________
Course Date: _________________________________________________________________

								
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