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  • 1. EUROPEAN SOCIETY FOR CLINICAL INVESTIGATION APPLICATION FORM FOR MEMBERSHIP After completion this form should be forwarded to the honorary secretary-treasurer. PLEASE TYPE OR USE BLOCK CAPITALS SURNAME ……………………………………………………………………………………………………… (or name of company in case of corporate membership) INITIAL(S) ……………………………………………………………………………………………………… (and surname of contact person in case of corporate membership) ADDRESS department ……………………………………………………………………………………………………… institute ……………………………………………………………………………………………………… street ……………………………………………………………………………………………………… postal/zip code, city ……………………………………………………………………………………………………… country ……………………………………………………………………………………………………… TELEPHONE ……………………………………………………………………………………………………… TELEFAX ……………………………………………………………………………………………………… E-MAIL ……………………………………………………………………………………………………… DATE OF BIRTH date, month in words, year ……………………………………………………………………………………………………… PRESENT APPOINTMENT ……………………………………………………………………………………………………… ACADEMIC DEGREES ……………………………………………………………………………………………………… SPECIAL INTERESTS ◊ 1 aging ◊ 15 immunology/autoimmune disease/transplantation ◊ 2 atherosclerosis/microcirculation/vascular disease ◊ 16 infection please identify areas of interest ◊ 3 body composition ◊ 17 lipids to a maximum of five (5) ◊ 4 bone biology ◊ 18 liver biology/hepatology ◊ 5 brain and nerve biology/neurology/psychiatry ◊ 19 kidney biology/nephrology ◊ 6 clinical pharmacology ◊ 20 nitric oxide/endothelium ◊ 7 connective tissue ◊ 21 oncology ◊ 8 diabetes/metabolism ◊ 22 phagocytes ◊ 9 endocrinology/thyroid ◊ 23 platelets ◊ 10 fatty acids ◊ 24 respiratory medicine ◊ 11 gastrointestinal biology/gastroenterology ◊ 25 cardiology/hypertension ◊ 12 genetics/reproduction ◊ 26 nuclear medicine/imaging ◊ 13 haematology ◊ 27 cell biology/molecular medicine ◊ 14 hormones/peptides/cytokines ◊ 28 muscle physiology Membership of the European Society for Clinical Investigation includes subscription to our monthly journal, the European Journal of Clinical Investigation. The current rates are: Euro 100 per year (individual membership), Euro 50 per year (junior membership), US$25.-/Euro 25 for Eastern-Europe members
  • 2. JUNIOR MEMBERSHIP  Any young scientist under the age of 30 can apply for junior membership of ESCI  Junior membership is for a maximum of three (3) years  Junior members receive the European Journal of Clinical Investigation and have the same financial benefits as full members  Junior members are not allowed to vote during the Annual Business Meeting, receive no membership certificate and are not eligible for any office  Junior members can apply for full membership at any time  Junior members pay a reduced membership fee (Euro 50. If junior members do not fulfill the requirements for full membership within the period of three (3) years, their membership will be terminated If you want to apply for junior membership and you meet the requirements above mentioned, please complete this form and send it to the honorary secretary-treasurer CORPORATE MEMBERSHIP Any company, corporation, organisation, or trust can apply for corporate membership in the Society. Applications shall be approved by the Council. Please return your application to: Dr Robin P. F. Dullaart, honorary secretary-treasurer of ESCI c/o Central Office European Society for Clinical Investigation Bolognalaan 34 3584 CJ Utrecht THE NETHERLANDS telephone +31 30 250 8787/telefax +31 30 251 5724/e-mail esci@digd.azu.nl

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