Clinical Excellence in Action: Multidisciplinary, Regional Perspectives on Advanced BRCA+ Prostate Cancer Case Management Name* First NameLast Name Email* example@example.com Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Organization* Do you give consent to CUA sharing your name and location ONLY to program sponsors? / Consentez-vous à ce que l’AUC révèle votre nom et votre lieu UNIQUEMENT aux commanditaires de nos programmes?* Yes / OuiNo / Non Which of the following best describes you? / Lequel des titres suivants vous décrit le mieux?* Please Select Urologist / Urologue Urologic-Oncologist / Uro-oncologue Urogynecologist Medical Oncologist / Oncologue médical(e) Radiation Oncologist / Radio-oncologue GP-Oncology / Omnipraticien(ne)/médecin de oncologie Nuclear Medicine / Médecine nucléaire Nurse / Infirmier(ière) Pharmacist / Pharmacien(ne) CUA staff / Personnel de l’AUC GP/FM / Omnipraticien(ne)/médecin de famille Medical Student / Étudiant en médecine Resident/Fellow / Résident/Boursier Other MD / Médecin — autre spécialité Other non-MD / Travailleur de la santé autre que médecin Industry / Travailleur de l’industrie pharmaceutique How did you hear about this event? / Comment avez-vous entendu parler de cette activité de formation?* Please Select CUA Email / Courriel de l’AUC CUA Website / Site Web de l’AUC Social Media / Médias sociaux From a Colleague / Collègue Industry Rep / Représentant de l’industrie pharmaceutique Other / Autre Information you provide when registering will be shared with the account owner and host and can be used and shared by them in accordance with their Terms and Privacy Policy. Register CUA Members: In order to have your Section 1 Group Learning Credits transferred to your Royal College MAINPORT dashboard: Please ensure that your Royal College ID number is included in your CUA membership profile (www.cua.org). Please register with the email that is associated with your CUA membership. Membres de l’AUC: Afin que vos crédits d’apprentissage collectif (section 1) soient transférés dans votre tableau de bord MAINPORT du Collège royal : Veuillez vous assurer que votre numéro d’identification du Collège royal est inclus dans votre profil de membre de l’AUC. Veuillez vous inscrire en utilisant l'adresse de courriel associée à votre compte de membre de l'AUC. This webinar is reserved for healthcare professionals and sponsoring companies. CUA reserves the right to cancel registration if deemed necessary. / Ce webinaire est réservé aux professionnels de la santé et aux entreprises commanditaires. L'AUC se réserve toutefois le droit d'annuler toute inscription si elle le juge nécessaire. Should be Empty: