Transcript PATROCINIO AIPO MODULO di RICHIESTA

PATROCINIO AIPO
MODULO di RICHIESTA
Da inviare esclusivamente a [email protected]
INFORMAZIONI SULL’EVENTO
TITOLO________________________________________________________________________________________________________________
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RESPONSABILE SCIENTIFICO_____________________________________________________________________________________________
 CONGRESSO
 SEMINARIO
 WORKSHOP
 CORSO
DATA DI SVOLGIMENTO __________________________________________________________________________________________________
LUOGO DI SVOLGIMENTO _________________________________________________________________________________________________
SEDE ____________________________________________________________________________________________________________________
RAZIONALE DELLA RICHIESTA ___________________________________________________________________________________________
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FINALITÀ DELL’EVENTO PER CUI SI RICHIEDE IL PATROCINIO ______________________________________________________________
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Modulo Rev. 4
Associazione Italiana Pneumologi Ospedalieri
Pagina 1 di 2
PATROCINIO AIPO
MODULO di RICHIESTA
Da inviare esclusivamente a [email protected]
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ALTRI PATROCINI RICHIESTI PER L’EVENTO _______________________________________________________________________________
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SEGRETERIA ORGANIZZATIVA
SOCIETA’/ENTE_________________________________________________________________________________________________________
REFERENTE _____________________________________________________________________________________________________________
TELEFONO/FAX__________________________________________________________________________________________________________
CELLULARE ___________________________________________ E-MAIL
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ECM
PROVIDER__________________________________________________________________________NUMERO____________________________
FIGURE PROFESSIONALI A CUI È RIVOLTO _________________________________________________________________________________
DISCIPLINE ______________________________________________________________________________________________________________
OBIETTIVI FORMATIVI____________________________________________________________________________________________________
NUMERO DI PARTECIPANTI PREVISTO _____________________________________________________________________________________
ORE TOTALI DI FORMAZIONE______________________________________________________________________________________________
ELENCO SPONSOR DELL’EVENTO__________________________________________________________________________________________
DATA DI INVIO DELLA RICHIESTA
IL RESPONSABILE SCIENTIFICO DELL’EVENTO - FIRMA
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SI ALLEGA AL PRESENTE MODULO PROGRAMMA PRELIMINARE/DEFINITIVO
Modulo Rev. 4
Associazione Italiana Pneumologi Ospedalieri
Pagina 2 di 2