PRESENTATION REGISTRATION FORM

Presentation (choose one ):

Poster presentation
Video presentation
Author(s):
No
Title
Urologist/ Urology Resident
First Name Surname Institution



Presenter :
Address :
Email :
Phone Number :
Presentation Title :

Hereby we stated that presentation content (video/poster) submitted is original, and we are responsible
for the material contained in the presentation. We give full permission to the organizing committee of
the 37
th
ASMIUA to use our presentation for professional purpose.
.................. , .......................... 2014

(signed here)
(Participant)