Application Form

EUROPEAN CANCER PREVENTION ORGANIZATION

MEMBERSHIP APPLICATION FORM

Please do not send payment at this time. You will be invoiced at a later date.

Please select one membership type (circle heading):

 

Active member

Open for all academics involved in cancer prevention.

 

Junior member

Available to trainees or researchers during the or 3 year immediately following the

completion of the training programme.

 

 

Associate member

Available to nonacademic

health care professionals.

 

Supporting member

Available to all individuals or organizations that will support the Organization

 

Demographic information

 

Name:
Title: Diploma:
Gender: Date of Birth:
Address:
Phone(s): Fax:
Email:
MD, PhD, other:

 

Professional information

Degree(s): Please include   institution and date granted
Training certification/diploma :
Start & End date Institution   Location Title:
Actual position:
Special field in cancer prevention that   is applicable for ECP functions and/or
committees:
Applicant signature:
Applicant name:
Date:
Application form should be sent to:

 

The European Cancer Prevention Organization

Member’s office
Klein Hilststraat 5 – 3500 Hasselt – Belgium
Tel +3211271557 – Fax +3211283677
Sabine.janssens@ecprevention.org

 

We look forward to welcome you as Member of ECP.

 

Kind Regards

Sabine Janssens

ECP

 

 

Bank
Dexia Bank
Pachecolaan 44
1000 Bruxelles
Belgium
 
IBAN No: BE19 0682 4294 4712
Account No: 068-2429447-12
SWIFT-code (BIC-code): GKCCBEBB

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