Application form

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    Privacy Policy (required) I Accept

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    The following informations will be used for our search engine. Please answer as precisely using the English diction

    Personal Datas

    First Name (required)

    Last Name (required)

    Your Email (required)

    Gender
    ManWoman

    Date of Birth(required)

    Website

    Occupation

    Other occupation

    Professional body

    Nr. of enrollment on the professional register

    Year of graduation

    Are You active in

    Other activity

    Specialisation / sub-specialisation(Please answer as precisely using the English diction)

    Other Specialisation (One or two word(s) to facilitate the research)

    Specific competences (For which diseases you can be recommended)

    Other specific competences (Please use a clear reference to facilitate the research)

    Specific treatment (For which treatment you can be recommended)

    Other specific treatment(Please use a clear reference to facilitate the research)

    Research in which you are involved

    Area of special interest ( not mentioned above )

    Area of special interest ( not mentioned above )

    Area of special interest ( not mentioned above )

    Languages in which you are able to offer consultations

    1st. selection

    2nd. selection

    3rd. selection

    4th. selection

    5th. selection

    Location

    Professional contact Address

    Town
    [cityfieldtext city]

    Post code

    Country

    Phone

    I agree to be consulted for the professional opinions
    YesNo

    I am interested in participating in European projects
    YesNo

    I am interested in representing the EMA in national or international conferences ?
    YesNo

    I would like to receive EPMA journal (**)
    YesNo
    (**) The Official Journal of the European Association for Predictive, Preventive and Personalised Medicine. ISSN: 1878-5085 (electronic version)

    For internal use only

    Private Address

    Town
    [cityfieldtext city_p]

    Post code

    Country

    Phone

    (** ) The scope and role of the Directory is to facilitate contacts, exchanges and cooperation within the health care professionals. Through this tool, our members can easily connect to each other, build partnerships and collaborations. It is a tool that we want to offer to colleagues to choose knowledgeably the best specialist responding to the needs of his patient

    I have read our privacy policy

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