Registration form
1:Name/Address
Title
Dr.
Ms.
Mr.
Academic title
Assist Prof.
Assoc Prof.
Prof.
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First name
Middle name
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Last name
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Preferred name on badge
Degree
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Department
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Organization/Institution
Cohost code
(For cohost institution only)
Mailing Address
Street
City
State
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Country
Afghanistan
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Antarctica
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Latvia
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Monaco
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Poland
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Puerto Rico
Qatar
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Romania
Russian Federation
Rwanda
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San Marino
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Spain
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Sweden
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Tanzania; officially the United Republic of Tanzan
Tibet
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Turkey
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Turks and Caicos Islands
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United Kingdom
United States
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Vanuatu
Vatican City State (Holy See)
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
ZipCode
*
E-mail
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Faculty of Nursing, Mahidol University
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