ΣΤΟΙΧΕΙΑ ΓΙΑ ΤΗΝ ΦΟΡΜΑ ΕΓΓΡΑΦΗΣ ΩΣ ASSOCIATE MEMBER ΤΗΣ ESAIC

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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