ESSIC MEMBERSHIP APPLICATION FORM
For scientists and/or medical practitioners only

Please use this form only


Number : ..................................... (for office use only)

   
TYPE OF MEMBERSHIP MEMBERSHIP FEE: € 50.00/year (50 euro)
full
associate
affiliate

full membership: for European residents
associate membership: for non-European residents
affiliate membership: for medical companies

see also: ESSIC by-laws

PERSONAL DATA
title(s)
first name(s)
family name
department
institute
address
postal code
city
country
phone
fax
e-mail

Signature




 Date

Place

 
PLEASE RETURN THE COMPLETED FORM TO THE ESSIC SECRETARIAT BY POST OR FAX TO:


ESSIC Secretariat
Dr J.P. van de Merwe
Erasmus MC
Department of Immunology, Room EE 828C
Postbus 2040
3000 CA Rotterdam
The Netherlands


fax (+31) 10 4089456
e-mail: info@essicoffice.org
website: www.essicoffice.org
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