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REGISTRATION FORM

(Deadline: 02 January 2017)

MEoM-CIMICC/PSO

13 Feb - 03 Mar 2017

AUTINT, GÖTZENDORF
(PCM/EE/AUT.271.22)
Attn: Course Administration
(Fax: 0043-50201-22 17323)
(E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.)

Surname:       ............................................................................................................
First name:   ............................................................................................................
Rank /Title:   ............................................................................................................
Date of birth:   ............................................................................................................
Nationality   ............................................................................................................
E-mail:   ............................................................................................................
Postal address:   ............................................................................................................
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Current assignment:   ............................................................................................................
Previous relevant training:   ............................................................................................................
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Means of transport:   ............................................................................................................
Place and time of arrival:   ............................................................................................................
     
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Date and Signature (by authorized person)