BEHRA Associate  Member Membership Form

See also the "News from the Nucleus"

If you wish to be an associate member of the Belgian Working Group on Cardiac Pacing and Electrophysiology, fill out the form below.

This position is available for cardiologists, internists, engineers, technicians, nurses ..

The professional activity of the applicant has to be totally or partly devoted to arrhythmology.

As an associate member you will be entitled to a reduced entrance fee at the Annual BEHRA Congress, to receive the annual belgian pacemaker implantation statistics and the Stimarec report (European PM failure registry).

An acceptance letter will be send to the candidate after reception of the application form and membership dues.

Please, do not use accentuated characters. Use only the mouse. Do not use "Enter" or "Return".

 

First name:

Last name:

Language:French  Dutch

Birthdate (dd/mm/yyyy):

Private adress:        

Professional adress:

Private phone:        

Professional phone:

Fax:

Email:                   

GSM:

Professional occupation:   

Arrhythmology occupation:

 

 

Enter the 5 numbers shown on the image here:              

You will receive an acceptance message after a few seconds  if the form is valid

A acceptance letter will be send to the candidate after reception of the application form and verification that all conditions are met.

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