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REGISTRATION - Public Health Event
The Denis & Lenora FORETIA Foundation is pleased to inform you that we will be organizing an event on Universal Health Coverage at the Foundation’s headquarters – Opposite College Jesus Marie, Simbock, on Tuesday 2019 from 10:00am to 12:30pm.
Name (Prénom, Nom de famille)
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Prefix
First
Last
Suffix
Address (Adresse)
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Street Address
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State / Province / Region
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Russia
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Australia
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Kiribati
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New Zealand
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Papua New Guinea
Samoa
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Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Email (courriel)
*
Phone Number (Numéro de téléphone)
*
Information About You (Informations personnelles)
This information is used solely for us to better understand our audience.
(Ces informations sont utilisées uniquement pour mieux comprendre notre auditoire.)
Age
*
Please select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
Gender
Please select
Male
Female
Current Employment Status / Statut professionnel actuel
*
Employed / Employé
Not employed / Sans emploi
Voluntary Unemployment / Chômage volontaire
Professional Affiliation (Select one (1) only) / Affiliation Professionnelle (Sélectionnez un (1) seulement
*
Government Employed (Civil Servant) / Employé du gouvernement (Fonctionnaire d'Etat)
Private Sector Employed / Employé du secteur privé
Self-employed / Travailleur indépendant
Student / Étudiant
Name of Employer / Nom de l'Employeur
*
If currently unemployed enter "None". If currently a student enter "Student". / Si actuellement vous êtes sans emploi, inscrivez «Aucun». Si actuellement vous êtes étudiant entrez "Étudiant".
What industry sector do you work in? Select only one (1) / Dans quel secteur industriel travaillez-vous? Sélectionnez un seul (1)
*
Please select
Administration/ Government
Agriculture
Educational Services
Financial Services
Health Care
Information & Technology
International Trade
Leisure & Hospitality
Local/national Trade including retail
Other
Student (if enrolled full-time with no source of income)
Transportation & Warehousing
Unemployed
Place of Birth / Lieu de naissance
*
Please select
South West
North West
Littoral
Center
South
West
East
Adamawa
North
Far North
Other African Country
Somewhere else
How did you first hear about this Roundtable? /Comment avez-vous entendu parler de cet forum ?
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Email from the Foundation
Facebook
LinkedIn
Television or Radio
Twitter
Friend or relative