Full Name *

Position *

Specialty *

Role in Medical Education * Select Assistant/Associate Dean Designated Institutional Official (DIO) Program Director Assistant Program Director Chair of Department Faculty Administration/leadership Institutional Coordinator Program Coordinator/Administrator Resident/Fellow Medical Student Other (Please specify if Other)

Organization * Select Department of Health – Abu Dhabi Dubai Health Authority Dubai Health (MBRU) Emirates Health Services (EHS) Zayed Military Hospital (ZMH) United Arab Emirates University (UAEU) University of Sharjah Abu Dhabi Health Services Company (SEHA) Cleveland Clinic Abu Dhabi Thumbay Healthcare University of Science and Technology of Fujairah Ajman University City University Ajman Burjeel Holdings Gulf Medical University Khalifa University AMBOSS Lecturio Medical Dubai Medical College Other (Please specify if Other)

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Gender * Select Male Female

Nationality * Select - Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Arabic Countries Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Islands Congo Congo, DR (Zaire) Cook Islands Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Dagestan Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Embassy in U.A.E Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island & McDonald Island Hellenic Republic Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Italy Jamaica Japan Jersey Jordan Kazakhastan Kenya Kingston Kiribati Kuwait Kyrgyzstan Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Magnolia Malawi Malaysia Maldives Mali Malta Marian Island Marshall Islands Martinique Martins Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles Nevis New Calcdonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Other Countries Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Regions of southern France Republic of Guinea Republic of Kosovo Republic of Montenegro Republic of Serbia Reunion Romania Russia Rwanda Ryukyu Islands Saint Christopher Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent Samoa San Marino Sandwich Islands Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Soviet Union Spain Sri Lanka St. Kitts and Nevis St. Vincent and Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Tasmania Thailand Timor Leste Togo Tokelau Tonga Tonga Islands Trinidad Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine Union Des Comores United Arab Emirates United Kingdom United States Minor Outlying United States of America Unknown Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Without Nationality Yemen Yugoslavia Zambia Zimbabwe kirgis

Category * Select Delegate Medical Student Member of NIHS Committees NIHS Surveyors NIHS Examiner Residents/Fellows Speaker Sponsor Program Directors Program Coordinator

Sponsor Code

Amount * AED