公益財団法人田附興風会 医学研究所北野病院

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Instructor dispatch reception

    Instructor dispatch application form

    Please enter the following information and press the send button.*Items marked with an asterisk are required.

    ◆ (Requester) Institution Name*
    ◆ (Requester) Position*
    ◆ (Requester) Name*
    ◆ (Requester) Email address*
    ◆ (Requester) Phone number*
    ◇ (Name of person you would like to request)*
    ◇ (The person you want to request) Affiliation, position, etc.*
    ◇ Request details*
    *If you select "Other"
    ◇Scheduled request date*
    ◇Scheduled request time*
    From timeUntil
    ◇Reward*
    *If there is a reward
    Aroundcircle
    ◇Transportation expenses*
    ◇Meals*
    ◇Other

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