APPLICATION FOR MEMBERSHIP

Surname: Title:

First Name:

Middle Name/Father`s Name:

Date of Birth:

Address:
           Street:

           Post Code: City/Town:

           District: Country:

Telephone Work: (a) (b)

Fax Work: Mobile telephone:

Telephone home: Fax Home:

E-mail address:

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Med. Practitioner     , Paramed. Professional     , Information Technology Scientist    

Profession/Specialty:

Place of Work:

Position:

Particular interests in relation to Medical Informatics:

Would you be interested in participating in committees of the society?   Yes    No

Possible topics:

Do you hold a university degree?   Yes    No

Date:

Note: Attaching acopy of the university degree is essential, except for doctors who are registered in the Medical Register of Cyprus

PO Box 16044 * CY-2085 Nicosia * Cyprus
Phone/ Fax: +315 (2) 760070 * E-mail: csmi@email.com
https://cymed.tripod.com/csmi.html