ΣΤΟΙΧΕΙΑ ΓΙΑ ΤΗΝ ΦΟΡΜΑ ΕΓΓΡΑΦΗΣ ΩΣ ASSOCIATE MEMBER ΤΗΣ ESAIC 2

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* 1. Name /Surname

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* 2. e-mail

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* 3. Title

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* 4. Date of birth

Date / Time

Date

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* 5. I hereby request as a member of the Hellenic Society of Anaesthesiology to
become an associate member of the ESAIC and approve that the Hellenic Society of Anaesthesiology shares the following data with the ESAIC:
First name, Last name, Email address, Title, Date of birth, Country:

Yes

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* 6. Date of application (today)

Date / Time

Date