Membership

Membership: Application form *

Name
First name
Title		Please press Crtl in order to choose more than one title.
Date of birth

Home address
Address
Postal code
City
Country
Telephone
Fax
E-mail

Work address
Institution
Address
Postal code
City
Country
Telephone
Fax
E-mail


Degrees and qualifications (date and awarding body)
Date	Awarding Body




Present Post


Main previous post


Special interests in neuropsychopharmacology (psychiatric, pharmaceutical, experimental, psychological, etc):


Membership of other relevant societies:


Please give the name and address of a worker in the field of neuropsychopharmacology from whom further details of standing can be obtained ( if requested by the Membership Committee)

Please send us a list of publications (mandatory).

*If it is not possible to submit your information via internet, please contact the scientific secretariat at ECNP + 31 30 253 8567. A printed version of the form will then be made available to you.

All information provided will be treated as confidential.

Membership - Application form