Registration Form For Hospital Center

Fields marked with * are mandatory.

Center name: *
Nation: *	-- SELECT NATION --ALBANIABELARUSBOSNIA AND HERZEGOVINA (Federation B&H)BOSNIA AND HERZEGOVINA (Republic of Srpska)BULGARIACROATIAHUNGARYISRAELITALYKOSOVOLATVIALITHUANIAMACEDONIAMOLDOVAMONTENEGROPOLANDROMANIARUSSIAN FEDERATIONRUSSIAN FEDERATION (SIBERIA)SERBIASLOVAKIASLOVENIASPAINUKRAINEUNITED KINGDOM
City: *
Address: *
Responsible user: *
Telephone: *
Academic Hospital: *	Yes  No
Hospital with cardiac surgery: *	Yes  No
Hospital with primary PCI: *	Yes  No
Hospital with Cardiac Cath Lab: *	Yes  No
Hospital with Coronary Care Unit: *	Yes  No
E-mail Address: *

Disclaimer

This form generates a request to join ISACS - Transitional Country.
The request needs to be approved by the ISACS National PI.
A confirmation email will be sent to you as soon as possible with further information.