Adnep Reg Sheet
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ASSOCIATION OF DIABETES NURSE EDUCATORS OF THE PHILIPPINES Moving People to Action 93 Apitong St. Marikina Heights, Marikina City Telefax: 942.03.13 Mobile: 0918.558.3666/0922.887.51.64 www.adnep.org
Date: _________________________
PARTICIPANT INFORMATION SHEET Name (last name)
(first name)
(middle name)
Profession MD
RN
RND
OTHERS: __________________
STUDENTS: Please specify course ____________________________ PRC No. and Expiry (for CPE units purposes) Residential Address Personal Contact Numbers
(telephone)
(cellphone)
(email address)
(telephone)
(cellphone)
(email address)
Institution/Organization Office Address Office Contact Numbers
Where did you hear about this activity? Colleague/Friend
Previous ADNEP actvity
Poster
Email
Website
Others ____________
Date: _________________________
PARTICIPANT INFORMATION SHEET Name (last name)
(first name)
(middle name)
Profession MD
RN
RND
OTHERS: __________________
STUDENTS: Please specify course ____________________________ PRC No. and Expiry (for CPE units purposes) Residential Address Personal Contact Numbers
(telephone)
(cellphone)
(email address)
(telephone)
(cellphone)
(email address)
Institution/Organization Office Address Office Contact Numbers
Where did you hear about this activity? Colleague/Friend
Previous ADNEP actvity
Poster
Website
Others ____________
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