MEMBERSHIP APPLICATION

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Surname *

Name *

Capacity *

Home address

Institution *

Street *

Number *

Postal Code *

Country *

City *

Street *

Number *

Postal Code *

Telephone *

Mobile *

Fax *

Optional citation of up to three research papers. *

E-mail *

Comment *

I have read and I agree with the terms of the HELANI Membership Regulation. *

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I agree with the publication of my contact information on the Academy's website as well as in written form once my application has been completed. *

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