Program Information
Program Name  
Program Location Preference

Contact Information
Select Program Date
Rep First Name
Rep Last Name
Contact Phone
District Phone
District Office Name
District Manager
Cost Center
Region

Contact Information
Select Program Date
Rep First Name
Rep Last Name
Contact Phone
District Phone
District Office Name
District Manager
Cost Center
Region

Contact Information
Select Program Date
District Office Name
District Manager
DSM
DA
Region

Participant Information

Prerequisites
See program overview on blueWire for each respective program.

First Name
Middle Initial
Last Name
Title (MD/DO, etc.)
Gender
Dietary Restrictions


(specify)
Mode of transportation
Ground Transportation needed
Hotel needed
Arrival Date
Departure Date
Specialty Practicing Physicians
Fellows
Preferred Mailing Address
Practice Name (if applicable)
Street Address
Apt./Suite/Dept.
City
State
ZIP Code
Contact Phone
E-mail
Valid Passport or Travel Documentation
for travel to Mexico (if applicable)
Customer licensed in the state of
Massachusetts or Vermont
Hospital Affiliation
Street Address
Apt./Suite
City
State
ZIP Code

Participant Information

Prerequisites:
All participants must have understanding of basic pacing concepts and physician should have a minimum of 3 identified patients with medical need for implants within 30 days of program completion.

For programs in Mexico, must have prior to program:

  1. Participated in Animal Lab Lead Placement Program and/or VCL Lead Placement, or
  2. Assisted in at least 5 human in-vivo implants (observational experiences do not qualify), or
  3. Equivalent experience prior to registering

First Name
Middle Initial
Last Name
Title
Gender
Dietary Restrictions


( specify)
Valid Passport or Travel Documentation
for travel to Mexico (if applicable)
Customer licensed in the state of
Massachusetts or Vermont
Specialty Practicing Physicians
Preferred Mailing Address
Practice Name (if applicable)
Street Address
Apt./Suite/Dept.
City
State
ZIP Code
Contact Phone
E-mail
Hospital Affiliation
Street Address
Apt./Suite
City
State
ZIP Code

Clinical Specialist Information

First Name
Last Name
Dietary Restrictions


(specify)
Preferred Mailing Address
Practice Name (if applicable)
Street Address
Apt./Suite/Dept.
City
State
ZIP Code
Cell Phone
E-mail
Number of years as a MDT CS
(minimum requirement 2 years)

Please read the following information carefully

Confirmation

  • Confirmation materials will be sent to program participant approximately one month in advance of the program start date with a cc to the district and regional offices.
  • If the physician selected from your region cancels their participation after you are confirmed to attend, you are still required to support the program even if the slot is refilled with a participant from a different region.

Travel

  • Valid Passport: All travelers must hold a valid passport to re-enter the United States by air in accordance with U.S. Federal Travel Regulations. Suggest the CS create an account with the U.S. Department of State.
  • You will need to make your travel arrangements through American Express Business Travel approximately 4 weeks in advance of the program and in accordance with MDT Travel Policy.
  • After making travel arrangements, please email a copy of your travel itinerary to your DA and Julie Chafin. This information is required to make your ground transportation arrangements from the Mexico airport to your hotel.
  • Arrival and Departure: Arrivals: Late afternoon or early evening the day prior to program start date. Departures: Mexico City- approximately 4:00 pm (no earlier than 3:00 pm), on the last day of the program. When possible, 90 minutes will be required for individuals with a connecting flight as you will need to clear customs at your first port of entry back into the U.S.

Expenses

  • Costs associated with your participation, including travel, should be charged to Cost Center #142039 and Project Code #MK50121.mkt. If you do not use the cost center number and project # code on your report, this will result in your expense express report being rejected and will require a resubmission on your part.

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