I am interested to receive ITCS information via e-mail (for free) (THE FIELDS MARKED WITH (*) ARE REQUIRED ENTRIES) Name (*) First Name (*) Title (*) Organization (*) WorkAddress (*) Country (work) (*) Phone (work) (*) Fax (work) (*) Email (work) (*) Private Address Country (private) Phone (private) Fax (private) Email (private) Preferred mailing address: work private I agree that my coordinates will be included in the ITCS membership directory and that my work coordinates will be used for distribution to tranplant related organizations. Tell us more about you... I am a (check all that apply): procurement transplant coordinator clinical transplant coordinator administrator (management) of OPO administrator (management) of Tx program data management coordinator (OPO) data management coordinator (Tx program) physician - organ/tissue recovery physician - organ/tissue transplantation Highest degree obtained (tick all that apply): BS BA BSN MSN Adnursing PhD MD other: I entered the field of transplantation in (month/year): I practice in one of the following areas (check all that apply): clinical inpatient*: intensive care general unit transplant unit operating room pediatrics other: clinical outpatient organ procurement* tissue procurement* preservation histocompatibility administration public education professional education hospital development other: I work in this field:Fultime Part-time (<35 hrs/week) *my job includes procurement or transplant of (check all that apply): kidney heart lung liver pancreas small bowel bone cornea skin other I am employed in the following type of facility (choose only one): community hospital university medical center Organ Procurement Organization : independent OPO hospital based OPO physician's office private foundation tissue bank other: I am primarily supervised/employed by (choose only one): physician/medical department or school hospital administration nursing department organ procurement agency government other:     If problems to submit this form via Internet, please fill in, print out, and send to: ITCS Executive Office, Pelgrimstraat 9/5, B-3000 Leuven, Belgium