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PARTIDO DE CONCERTACIÓN NACIONAL

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REDES SOCIALES OFICIALES

LEGISLADORES DE CONCERTACIÓN NACIONAL

Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

Día

Mes

Año

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

PCN

Dirección Sede Nacional PCN

Col. Las Mercedes, Calle Los Granados #37.

San Salvador, El Salvador.

(503) 2223-2670 / 2223-2675

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