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ANNEE UNIVERSITAIRE 2020 - 2021
FICHE DE PRE-INSCRIPTION
Diplme dUniversit de REANIMATION HEPATIQUE
FORMCHECKBOX Mr FORMCHECKBOX Mme FORMCHECKBOX Mlle
Nom:
Nom de jeune fille:
Prnoms:
Date de naissance: Nationalit:
Adresse personnelle :
CP:_________________ Ville:____________________Pays:___________________
Tlphone :
E-mail:
Adresse professionnelle :
CP:_________________ Ville:____________________Pays:___________________
Formation actuelle :
FORMCHECKBOX Praticien hospitalier FORMCHECKBOX Interne FORMCHECKBOX Rsident FORMCHECKBOX Mdecin tranger
FORMCHECKBOX Autres, prcisez :
Spcialit:
Cette fiche accompagne dun C.V., dune lettre de motivation et une attestation de fonction renvoyer ladresse suivante:
D.U. Ranimation Hpatique Pr. Didier SAMUEL
Centre Hpato-Biliaire - Hpital Paul Brousse, 12-14 av P.V Couturier 94800 VILLEJUIF
Tel. +33 1.45.59.34.11 Fax. 33 1.45.59.38.57 - Email: HYPERLINK "mailto:durea.chb.pbr@aphp.fr" durea.chb.pbr@aphp.fr
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