Application Form of
The International Minimally Invasive in Spinal Surgery
(MISS) Course
1. Personal Information
Name :
Institution :
Department :
Address :
Phone Number :
Fax Number :
Email Address :
Date of Birth :
Place of Birth :
Citizenship :
2. Minimally Invasive Spinal Surgery (MISS) Background
How many times have you participated in a MISS Workshop?
How many MISS procedures do you complete every month?
Have you attended annual MISS Meeting or Congress?
Have you presented the paper at MISS Meeting?
If yes how many times?
3. Field of Interest
Please write 3 topics of your interest or the surgery that you want to learn during the course.
1.
2.
3..
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3. Desired Date in 2015 (Please check ‘V’ on blank boxes)
 88th
 89th
 90th
 91st
 92nd
 93nd
 94th
January
March
April
June
August
October
November
12 ~ 16
16 ~ 20
13 ~ 17
15 ~ 19
10 ~ 14
12 ~ 16
23 ~ 27
(5 available)
(5 available)
(5 available)
(5 available)
(5 available)
(5 available)
(5 available)
4. Application submission and Course fee
All applications (application form, CV, and accommodation form) must be sent one month
prior to the course. The course fee of US$3,000 must be paid two weeks before the course.
The course fee will be refundable at 50% (US$1,500) in case of cancellation 7 days before
the date of the course. The fee will not be refundable (US$0) if cancellation is less than 7
days before the date of the course. Only bank transfer is acceptable. Please see below for
bank information.
SIGNATURE:
DATE:
♦ Please send the application form, CV, and accommodation form to the
following address:
Ms. JaeEun Park
Wooridul Spine Hospital
47-4, Chungdam-dong, Gangnam-gu
Seoul, 135-100, Korea
Tel: +82 2 513 8949, Fax: +82 2 513 8154
E-mail: parkje16@wooridul.co.kr
♦ Bank Transfer Information
1. Swift Code: CZNBKRSE
2. Name of Bank: KOOKMIN
3. Address of Bank: 76-4, Chungdam-dong, Gangnam-gu, Seoul, 135-100, Korea
4. Account Number: 537568-03-100290
5. Beneficiary’s Name: Wooridul Spine Health
6. Beneficiary Address & Tel. No: 47-3, Chungdam-dong, Gangnam-gu,
Seoul, 135-100, Korea
7. Contact #: Tel: +82 2 513 8949, Fax: +82 2 513 8154
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