CLINAM-Foundation: The Application for membership

I / We would like to become a member of the European Foundation for Clinical Nanomedicine as
Individual Member: no annual membership fee
Individual Patron Member: annual membership fee is 200 €
Corporate Member: no annual membership fee
Corporate Patron Member: annual membership fee is 3'000 €
ESNAM-Member (=member of the European Society for Nanomedicine): no annual membership fee

Title:
First name:*
Last name:*
Profession:
Company / University:
Department / Affiliation:
Address:*
ZIP code:*
Town:*
Country:*
Phone:*
Fax:
E-Mail:*

I work clinically.
yes no

I am involved in nanomedical applications as a scientist / researcher.
yes no

	I don't want to sponsor the foundation at present. But you may contact me again later again.
	I would like to make a contribution of € to the foundation.
	Please invoice me for the above mentioned amount.
	Please send me an attestation on the tax deductibility of my sponsoring.
	Please contact me. I want more information and discuss with you.

I am / we are interested in:

	Receiving the European Journal for Clinical Nanomedicine (academic journal)
	Information about the scientific conferences and activities of the network
	Ethical and philosophical debates on nanomedicine

In case that you are handling the application for someone else, please tell us your name, address, and E-mail contact.

Name of sender:
Address:
ZIP code:
Town:
Country:
E-Mail:
Phone:

I agree that these data are used according to the legal regulations, including maintenance of the membership list and for information transfer between the European Society for Nanomedicine, the European Foundation for Clinical Nanomedicine and the members.