APPLICATION FORM FOR INSTITUTIONAL MEMBER

(NON PROFIT INSTITUTION, MEDICAL ASSOCIATIONS, , UNIVERSITIES , PATIENTS ASSOCIATION )

Institution

Annual membership fee : 1.000,00€

IBAN Code : BE98 2100 6246 2493 – BIC : GEBABEBB

Institution name (acronym & full) (required)

Address (required)

Country(required)

Phone Nr (required)

Website

Category (required)

Legal representative

MrMrsMissMs

Last name (required)
First name (required)
Position (required)
Address (required)

Phone Nr (required)

Email (required)

I agree to become a full Institutional Member of the European Medical Association (E.M.A.) and to abide by its statutes.