EUBS MEMBERSHIP APPLICATION FORM

1. Personal Details - see (1):
Name
First name
E-mail (must be unique)
Title	Dr. Dr.(med) Mrs. Miss Mr Other
Educational qualification (see note (2, 3, 4)) (Degree, Date, University)

Professional information
Institution
Address (street - number)
City		Zip
Country
Phone - see (5)		Fax
Personal information
Address (street - number)
City		Zip
Country
Phone - see (5)		Fax


I would like my copy of D&HM sent to :
Special interests	hyperbaric oxygen therapy	hyperbaric physiology	diving medicine
	diving physiology	hyperbaric technics	fundamental research
	clinical research	regulation and legislation	training and education
Please list 2 EUBS members familiar with your work / interest in underwater or hyperbaric medicine (3): *Note*: if you do not know anybody in the Society who can second your membership application, please mark: "Member1" and "Member2" as names, and "EUBS" in all the other fields below. Please either provide a short CV in the "Additional Information" box, or send your CV to our membership secretary by e-mail.
EUBS member 1	Name
	City
	Institution
EUBS member 2	Name
	City
	Institution
Additional information you wish to provide:

(1) : Underlined items must be filled in
(2) : For undergraduate membership, state course being studied and expected date of graduation
(3) : Undergraduate members must have the support of their senior faculty member
(4) : Where a waiver under Bylaw II requires a 'special accomplishment' this must be well documented
(5) : The following characters are valid for the phone number : 0-9, +, -, /, \, ., (, ), and space.

Note : Only your professional address, professional phone and e-mail will be made visible to registered members.