Create-an-account

Registration

Title:
Name:
Surname:
Username:
Date of Birth (dd/mm/yyyy):
Nationality:
Position held:
Institution:
Hospital address:
Mailing address:
City:
Zip code:
Country:
Home address (optional):
Mailing address:
City:
Zip code:
Country:
Telephone:
Fax:
Email:
Password:
Verify Password:
Enter your WFITN code:
Reference 1:
Name, Surname:
Hospital:
Relationship to applicant:
Reference 2:
Name, Surname:
Hospital:
Relationship to applicant:
Specialty accreditation for appropriate geographic region:
Radiology:
Neuroradiology:
Neurosurgery:
Other:
Certification Agency:
Certification Date:
Organization:
Applicants must include information about their diagnostic/neurosurgery training:
When did your training start?:
When will/did your training end?:
Last year of training:
Institution:
Name of program director:
Phone number:
Neuroradiology / interventional neuroradiology / other training:
First year from:
When will/did your training end?:
Institution:
Director of training:
Phone:
First year from:
When will/did your training end?:
Institution:
Director of interventional neuroradiology training:
Phone:
Additional years: