Registration
 Please  fill the form and send by e-mail:  gisc@posta.ge
           

GEORGIAN INTERNATIONAL SOCIETY OF CARDIOMYOPATHY

Member  N  ________

1 Surname -----------------------------------------------------------------------------------------------------------
Name -----------------------------------------------------------------------------------------------------------
2 Date of birth -----------------------------------------------------------------------------------------------------------
3 Specialty -----------------------------------------------------------------------------------------------------------
4 Institute -----------------------------------------------------------------------------------------------------------
5 Degree -----------------------------------------------------------------------------------------------------------
6 Date of membership -----------------------------------------------------------------------------------------------------------
7 Adress -----------------------------------------------------------------------------------------------------------
8 Telephone -----------------------------------------------------------------------------------------------------------
9 E-mail -----------------------------------------------------------------------------------------------------------
10 Sign of member -----------------------------------------------------------------------------------------------------------
Note -----------------------------------------------------------------------------------------------------------
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President  of GISC