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 :
Professional address
Private address
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.
