(Please complete with full, legal name and no abbreviations)
*The application is open to U.S. based surgeons only*
* Denotes a required field    
* First Name:  
  Middle Name:  
* Last Name:  
* Email Address:  
* Hospital Name:  
* Hospital Street Address 1:  
  Hospital Street Address 2:  
* Hospital City:  
* Hospital State:  
* Hospital Zip:  
* Office Phone #:  
* Key Office Contact Person:  
* Key Contact Person Email:  
* Key Contact Person Phone #:  
       
* Home Street Address:  
* Home City:  
* Home State:  
* Home Zip:  
* Cell Phone:  
       
* Citizenship:  
* Date of Passport Expiration:  
* Have you been to Russia before?  
  If Yes, Date of Last Visit:  
       
* Years of experience with Circular Fixation:  
* # of Circular Fixation frames done per year:  
* What system(s) do you currently use?  
       
* Upload your CV: (Filename cannot contain punctuation)  
       

 

I understand that a portion of trip expenses will be underwritten by SBi. Confirmation of the expected cost to attendees will be outlined upon application acceptance.

Note: This is an application only. All applications will be reviewed by SBi. Should your application be accepted, you must have a valid passport that doesn’t expire in the year 2013 in order to attend this course.