MEMBERSHIP APPLICATION FORM
The membership is free of charge
to Sleep Technologists/Nurses.
Name, Firstname (Mr/Ms) _________________________,
__________________
Home Address _____________________________________________________
Zip Code, City _______________ -______________________________________
Country _________________________________________
Phone __+ ______________________GSM ______________________________
Home E-mail _________________________@____________________________
ICQ-number (optional)________________ skype ___________________________
Professional Address ________________________________________________
Zip Code, City _____________-________________________________________
Phone__+_______________________Fax________________________________
Work E-mail __________________________@___________________________
(optional)
Professional Experience _______________________________________________
Years employed as sleep technologist _____________________________________
Other Professional Membership _________________________________________
Types of studies performed ____________________________________________
Remarks __________________________________________________________
Please send correspondence to my: home address /
work address
Please indicate which phone number should be published : work
/ home
Date ______________________ Signature ________________________________
Send, fax or mail this form to:
Diane Zeeman, ESST Secretary
MCH - locatie Westeinde - Centre for Sleep and Wake Disorders
PO Box 432 - 2501 CK Den Haag
The Netherlands
Fax: +31-70-3882636 - E-mail
Please, in any case, send this
membership application form to the Society address.
Members will receive the ESST Newsletter, the addresses
directory of European Technologists (only on request), reduced
international conference fees and the opportunity to compete
for international research and travel awards.
Thanks you very much.
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