APPLICATION FOR MEMBERSHIP

Personal Information

Last Name	First Name(s)	Position/Title

Birthdate


Nationality	Passport Number (or ID)

Contact Details

Address		Postal
City		Country
Telephone		Fax
Mobile		Email

PROFESSIONAL INFORMATION REQUIRED

all documentation must be in English

1. Nationality:

Copy of passport or ID card required

2. Specialisation:

Copy of Certificate OR letter of attestation of status from EADV member is required

First Medical Degree

Date	University	Country

Specialist Status:

Date	University	Country

3. PhD:

(if applicable- scientists) Doctoral award:

Date	Institution	Country

Topic

4. Trainee:

Enclose official certificate of training and dates of entry and presumed completion

5. If retired:

Enter the date of first joining EADV

6. Endorsers:

THREE EADV Specialist members must endorse application confirming that, in their opinion, the applicant in question is a fit and proper person to be admitted to membership of EADV

	Name	EADV Number
Endorser 1
Endorser 2
Endorser 3

APPLICANT's SIGNATURE

The confirmation of identity form with original signature must be sent by post.

ANNUAL DUES 2011

The relative dues are revised annually by the Board of Directors

European:

Ordinary: € 170, Specialists: € 150, Trainees: € 75*, Retired: € 75

Non-European:

€ 150, Trainees: € 75 (E -version of JEADV)

*extended until age 35 to those attaining specialist qualification

PAYMENT METHOD

Bank transfer, or

Credit Card

Bank details information will follow with request of payment upon approval of your application for EADV membership.

B. ORGANISATIONS

Letter and references to be send to the Secretary General.

If you do not receive a response in the next 10 days, your application may not have gone through and you are advised to check directly with EADV in Brussels, Belgium at:

EADV (succursale belge) - 38 avenue General de Gaulle - 1050 Brussels - Belgium
Phone: +32 2 650 00 90
Fax: +32 2 650 00 98
membership@eadv.org

ADDITIONAL IMPORTANT INFORMATION FURTHER TO DETAILS ON APPLICATION FORM

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