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Your Information

Workshop Preference *

Note: This workshop is a combined course. Please select your preferred workshop specialty.

First Name *

Last Name *

MD/DO *

MD DO Resident Consultant Fellow PA

Hospital Affiliation *

Hospital Address Line 1 *

Hospital Address Line 2

City *

Postal Code *

State / Country *

If other, please list the country *

State / Country *

Country *

Zip / Postal Code * (or N/A if not applicable)

Primary Phone *

Cell Phone *

Email *

Twitter Handle

Medical License # * (or N/A if not a US surgeon)

Medical License State * (or N/A if not a US surgeon)

If other, please list the country *

Medical License Country *

National Provider Identifier (NPI) * (or N/A if not a US surgeon)

Surgical Specialty *

Surgical Specialty * (Other - please specify)

Sales Rep * (or N/A)

Latex Glove Allergy? *

Yes No

Travel Arrangements

Applied is happy to assist in the coordination of your travel arrangements. Please answer the questions below:

Do you require a flight to attend the workshop?*

Yes No

Applied Medical is happy to assist you in booking your flight or you may choose to self-book. Please choose from the following options: *

Option #1:
Applied will research flights for you, based on your responses to the below questions. Prior to booking, a Clinical Education Coordinator will reach out to confirm your preferred itinerary and obtain your credit card details to book flights on your behalf. You will be provided with a receipt and you may submit it post course for reimbursement per the Travel and Expense Reimbursement Guidelines referenced below.

Preferred Departure Airport *

Preferred Departure Date *

Preferred Departure Time *

Full name as it appears on your ID used for travel*

Date of Birth*

Phone number*

TSA Precheck Number (if applicable)

Frequent Flyer Number and Airline (if applicable)

Option #2:
You may book your flights yourself and submit a receipt post course for reimbursement per the Travel and Expense Reimbursement Guidelines referenced below.

Please check this box to confirm your understanding that you will be responsible for payment of your flight initially.*
You must submit an itemized receipt for your flight which shows the date, city of origin, destination of travel and proof of payment to be eligible for reimbursement. Please Note: Applied will reimburse reasonable coach-class fares only. Bag check-in, extra leg room and fare upgrade expenses are not reimbursable.

Do you require a hotel room to attend the workshop?*

Yes No

Applied Medical can reserve a hotel room on your behalf for this course. Hotel rooms are reimbursed for one night only unless preapproved for multiple nights.

Please confirm which night(s) you need and we will book you a hotel room.

Requested Check-In Date *

Requested Check-Out Date *

Please check this box to confirm your understanding that Applied Medical will only reimburse for one hotel night, at the Applied rate, unless you are preapproved for multiple nights. If you need multiple nights, reach out to clinicaleducation@appliedmedical.com to get preapproval. *

Please Note: Hotel entertainment and mini-bar expenses will not be reimbursed. If any meals or hotel parking are charged to your room, you must submit all your original itemized receipts showing proof of payment to be eligible for reimbursement.

Reimbursement Guidelines
All course expenditures are initially paid by the surgeon and are reimbursed after the course, according to the guidelines attached. Please check this box to confirm that you have read and agree to the Travel and Expense Reimbursement Guidelines. *

Billing Information

Name on Card *

Card Type *

Card Number *

Security Code *

Expiration Date *

Billing Address

Use same address as in Your Information

Address Line 1 *

Address Line 2

City *

State / Country *

If other, please list the country *

State / Country *

Postal Code *

Country *

Zip / Postal Code *

Your Information

,
,
,

ML #:

ML State:

ML Country:

Hospital Affiliation(s)

National Provider Number (NPI)

Surgical Specialty

Sales Rep

Latex Glove Allergy

Billing Information

Credit Card

Billing Address

,
, ,

Fee

The disclosure of this data is voluntary. By providing your personal data you give your consent to Applied Medical to process your personal data and follow-up on your request for more information on the e-mail address and/or phone number provided by you on this form. Applied Medical will not transfer your personal data to third parties unless required to do so by law and shall take all appropriate measures to protect your personal data from unauthorized access. We will retain your data in our CRM database. Your consent can be withdrawn at any time by contacting clinicaleducation@appliedmedical.com.
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Transanal Minimally Invasive Surgery (TAMIS) Course

Your Information

Policy Agreement

Registration Fee

Cancellation Policy

For additional course logistics, please contact:

For additional course logistics, please contact:

For additional course logistics, please contact:

Photography/Video Notification and Consent

Photography/Video Notification and Consent

Travel Arrangements

Travel Arrangements

Travel Arrangements

Clinical Information

Billing Information

Billing Address

Your Information

Hospital Affiliation(s)

National Provider Number (NPI)

Surgical Specialty

Sales Rep

Latex Glove Allergy

Billing Information

Credit Card

Billing Address

Fee

CONTACT