BRI Medical Imaging Equipment Seminar-Information Collection Form
Welcome to the participant information collection for Seminar on Medical Imaging Equipment Configuration and Management for Belt and Road Countries. This form contains 4 sections, with an estimated completion time of 7 minutes.
Note: All information collected will be used solely for program administration and emergency purposes and will never be shared with third parties without your consent.
For any help, please contact our volunteers. Thank you for your cooperation!
Section 1/4: Personal & Educational Background 1. Surname:
2. Given Name:
3. Preferred Name:
4. Gender: Male Female Prefer not to say
5. Age: (Number only, e.g., 42)
6. Date of Birth: (YYYY-MM-DD)
Use the calendar: Click on day numbers to select your date. 7. Marital Status: Single Married Other Prefer not to say
8. Education Level: High School Bachelor's Degree Master's Degree PhD Other
9. Place of Birth: (City/Country, e.g., Beijing, China)
10. Nationality:
11. Passport Nationality Abbreviation: (3-letter code, e.g., CHN for China)
Section 2/4: Passport & Visa Information
Note: All passport details will be securely stored and only accessed by authorized staff.
12. Passport Number: (e.g., AB123456)
13. Passport Expiry Date: (YYYY-MM-DD)
14. Arrival Date in China: (YYYY-MM-DD)
15. Departure Date from China: (YYYY-MM-DD)
16. Visa Expiry Date: (YYYY-MM-DD)
Section 3/4: Work Information & Contact 17. Official Language(s): English French Spanish Russian Arabic Chinese Other
18. Native Language(s): (e.g., Swahili)
19. Sending Country/Organization: (e.g., Ministry of Health, China)
20. Organization: (Optional, if different from sending organization; e.g., West China Hospital)
21. Job Title: (e.g., Senior Medical Officer, Radiologist)
22. Email Address:
23. Mobile Phone: （Include country code, e.g., +86 13812345678)
24. Mailing Address: (Full address in English, e.g., 123 Main St, Beijing, China)
25. Permanent Address in Home Country: (Optional, if different from mailing address)
26. Postal Code: (Optional)
27. Fax Number: (Optional)
Section 4/4: Additional Information 28. Religion: (e.g., Christian, Muslim, None)
29. Dietary Restrictions: (e.g., Vegetarian, Halal, Peanut Allergy, None)
30. Blood Type: A B AB O Other:
31. Hobbies/Interests: (Optional, e.g., Swimming, Photography)