Application for Membership

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Applicant Information

Please provide your personal information.

Gender*

Title

First Name*

Last Name*

Organization Information

Please fill in the following fields if you are applying on behalf of an organization.

Hospital or Institution

Institute/Dept.

Address and Contact Information

If you are applying as an individual, then please provide your residential address and personal contact information.
If you are applying on behalf of an organization, then please provide your office address and business contact information.

Address*

Country*

City / Town / Village*

ZIP / Postal Code*

Telephone*

Email*

Application Nature

Please select which of the following applies for you.

Applying for

[Professional] Active membership (paediatric surgeons only) – 100,00 EUR p.a.

[Academic] Paediatric surgeon in training – 100,00 EUR p.a.

When do you expect to complete your training?*

Endorsements

Please provide the full name and the endorsement validation code provided by your endorsing EUPSA active members.

Active member #1*

Code #1*

Active member #2*

Code #2*

Journal

I am interested in subscribing to the "European Journal of Pediatric Surgery"

Please click here to review European directive on privacy policy laws No.196 of 30-June-2003 before proceeding with the submission of this application.

I hereby authorize the treatment of my personal data according to the current European directives on privacy policy.

Attachments*

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Accepted file types: doc, docx, odt, pdf, Max. file size: 7 MB, Max. files: 3.

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