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Registration to the conference

Nationality
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Name (*)
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Surname (*)
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Place of residence (*)
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Email (*)
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Birth (*)
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Tel. Home
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Tel. Office
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Tel. Mobile
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Male / Female (*)
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Speciality (*)
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Hospital / Office (*)
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Hospital / Office address (*)
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Have you ever experienced any healing cases by prayer ? (*)
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Do you have some divine healing cases that you want to present at the international Christian medical conference ? (*)
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I'll arrive to Rome the:
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At:
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Place of arrival:
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I'll arrive:
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I will stay for one night in the hotel:
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I'll leave Rome the:
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At:
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Place of departure:
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Particular recommendations:
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