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