Please send the completed form to:
EBMT Executive Office,
Edifici Dr. Federic Duran i Jordà
Passeig Taulat, 116, 08005 Barcelona - Spain
Tel: (+34) 93 453 8570 · Fax: (+34) 93 451 9583 · e-mail:
EBMT MEMBERSHIP APPLICATION FORM
IndividualEBMT Nurse
Please note that if you are already listed in a centre, you do not need to apply for this membership as you enjoy the same rights and privileges being in a centre as being an individual member.
Please print clearly
Surname: / Name :Institution:
Department:
Street:
City: / Post code:
State:/Province: / Country:
Phone: / Fax:
E-mail: (compulsory)
If you are an Indian nurse, please check the following box
MEMBERSHIP FEE:
The annual fee is 40 Euro which covers one individual member.
**The annual fee for nurses residing and working in India is 20 Euro. If you are applying from India, please attach a scanned copy of your hospital identification badge**
Please do not send cheques with your application form. Applicants will receive an invoice from the Financial Department following acceptance of their application.
SPONSORSHIP:
Sponsorship by two EBMT members with Full or Associate membership is required.
1st Sponsor:Name and CIC ......
Signature: ......
2nd Sponsor:Name and CIC ......
Signature: ......
COMMITMENT: By signing below, I certify that I am actively involved in the scientific and clinical area of blood or marrow transplantation (or transplantation of other haematopoietic tissue) and have worked in the field for over two years.Bysigningthis contract I declare that I understand and accept that my personal data will be incorporated in a file property of EBMT which can be allocated outside the EU. The EBMTwill use your information only for the purposes for which you submitted the information.
The Data Subject shall have the right of access to his or her data and the right to rectification of any inaccurate or incomplete personal data. If the processing operation is unlawful the Data Subject has the right to request deletion of that data.Please write to
Date: ...... Signature: ......
Appendix A: BENEFITS FOR THE EBMT Individual Nurses
Individuals Nurses have the following rights and obligations:
1)Participate in activities of the Working Parties
2)Receive information about Board and other activities, co-operative studies, and results of EBMT research projects
3)Have access to the EBMT Registry and to statistical overviews of transplants (subject to current privacy regulations)
4)Be eligible for reduced fees to attend the Annual Meeting of EBMT
5)Be eligible for reduced registration fees to EBMT educational events.
6)Receive EBMT Newsletters 6 times per year
7)Access the annual results of the EBMT Transplant Activity Survey on the website ( > Research > Transplant Activity Survey > Results)
8)Be eligible for an individual discount of 50% to the subscription to the Official Journal of the EBMT, Bone and Marrow Transplantation Journal.
9)Submit data for presentation at the annual meeting