<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%> Untitled Document
 




 

PART 1 - PERSONAL INFO

<% If Session("errorMsg")<>"" And Request("errorFlag")="1" then Response.Write(Session("errorMsg")) End If %>

Title*Prof. <%If (CStr(Request.QueryString("title")) = CStr("Prof.")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" name="title" value="Prof."> Dr. <%If (CStr(Request.QueryString("title")) = CStr("Dr.")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" name="title" value="Dr."> Mr. <%If (CStr(Request.QueryString("title")) = CStr("Mr.")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" name="title" value="Mr."> Ms. <%If (CStr(Request.QueryString("title")) = CStr("Ms.")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" name="title" value="Ms.">
First Name* "> Family Name* ">
Address* " size="90">  
City* "> Country* "> Postal Code* ">
E-mail * "> Telephone* "> Fax ">
 
Company/Institution* " size="90">
Department " size="90">  

MAIN FIELD OF ACTIVITY
Vascular Surgeon
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Vascular Surgeon")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Vascular Surgeon">
General Surgeon
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("General Surgeon")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="General Surgeon">
Interventional
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Interventional")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Interventional">
 
Radiologist
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Radiologist")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Radiologist">
Pediatric Surgeon
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Pediatric Surgeon")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Pediatric Surgeon">
Pediatrician
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Pediatrician")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Pediatrician">
 
Dermatologist
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Dermatologist")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Dermatologist">
Investigator
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Investigator")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Investigator">
Phlebologist
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Phlebologist")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Phlebologist">
 
Lymphologist
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Lymphologist")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Lymphologist">
Angiologist
<%If (CStr(Request.QueryString("fieldOfActivity")) = CStr("Angiologist")) Then Response.Write("checked=""checked""") : Response.Write("")%> type="radio" onClick="clearOther(this.form)" name="fieldOfActivity" value="Angiologist">
Other
" size="20">