ESLAV
Membership Application Form
Please note that this data will be kept in electronic format and used for
the administration of the association.
By signing this document you are agreeing
to this. Click
here to read application procedure.
Membership Application Form
Please note that this data will be kept in electronic format and used for the administration of the association. By signing this document you are agreeing to this.
Name (LAST, first):
Please circle the appropriate: Male Female
Title / Position:
Organization:
Address:
Phone: Fax: E-Mail:
Qualifications:
Date and place of veterinary degree:
Field of interest in laboratory medicine:
Two current
members of ESLAV who know you:
*
*It is necessary that two
current members of ESLAV vouch for each applicant. If you are not able to name
two current members please include your CV plus a list of LAS meetings you have
attended and/or a list of publications on your LAS research work.
1.
2.
Are you a member of LAVA (Laboratory Animal Veterinary Association):
Annual Fee: 45 Euros
Credit Card Number: Type of CC: (Visa or Master Card only)
3-digit security code”:
Expiration Date:
"If, for confidentiality reasons, you do not wish to communicate this information by fax or e-mail, you could call the ESLAV Treasurer, Dr. Delphine DENAIS, Tel: + 33 5 63 71 42 52 or 42 15
Bank transfer to:
Bank code: 30004
Agency code: 00748
Bank account N°: 00010023241
Cle RIB: 72
BNP Castres SWIFT: BNPAFRPPCAS
Iban N°: FR76 3000 4007 4800 0100 2324 172
Once the application has gone through the formal process the Treasurer will get in touch with you about the payment. To keep bank fees low we ask you to pay by Credit Card or by bank transfer. If you wish to pay by other means a banking charge may be applied
Date and Signature
Please print this form. Mail it, fax it or E-Mail it to josten.markus@rcc.ch Fax: +41 61 901 2565
European
Society of Laboratory Animal Veterinarians
c/o Dr. Markus Josten
RCC Ltd
Woelferstrasse 4, CH-4414 Fuellinsdorf
Switzerland