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ESBICM Membership Form
Make sure to fill all the details correctly as incomplete or incorrectly filled details can lead to rejection of your application.
* Indicates required question
Email
*
Record my email address with my response
Full Name
*
Your answer
Gender
*
Choose
Female
Male
Other
Profession
*
Choose
Doctor
Nurse
Paramedic
Other
Qualification
*
Your answer
Country
*
Your answer
State
*
Your answer
City
*
Your answer
Pincode
Your answer
Contact no.
*
Your answer
Current associated institute or organisation (if any)
Your answer
If you are interested in teaching bedside intensive care, how would you like contribute or share your knowledge?
*
Online webinars/meetings/classes
Videos/tutorials (self made)
Writing articles for ESBICM blog or website
Not interested in teaching
Other:
Required
Would you like to become ESBICM Academic Volunteer
*
Yes
No
In future, will you be interested in organising ESBICM Academic event in your institute or city? (online and physical)
*
Yes, but only online
Yes, online and physical both
No
How you came to know about us?
Your answer
Comment (anything you want to say or share with us)
Your answer
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