Registration Form

WAITING LIST DSATC

Position

Resident

Medical specialist

Start of Surgical Training

Medical Specialist Since

Medical specialism *

Trauma Surgery

Surgery

Orthopedic Surgery

Other / not applicable

Operative experience in polytrauma cases *

Less than 10 cases

Between 10-30 cases

More than 30 cases

Other/ not applicable

Dhr/Mw *

Titel

Voornaam *

Achternaam *

Land *

Postcode *

Huisnummer *

Straat *

Plaats *

Date of birth: *

E-mailadres *

Function

Organisation

Z-number (only for Radboudumc employees)

BIG nr. (in case you do not have a BIG nr please fill in zero) *

I agree with the general terms and conditions *

Wachtlijst DSATC