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Official journal of the International Society Revue officielle de la ...

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Vesalius, VI, 2,160, 2000Application for membershipFormu<strong>la</strong>ire <strong>de</strong> candidatureTitres: Mr. Mme. Dr. Pr<strong>of</strong>.Style and titles: Mr. Mrs. Dr. Pr<strong>of</strong>.Nom/Surname :Prenoms/Forenames :Adresse/Address :Tel./Phone: + /.Fax : + /.E-mail :Nationalite/Nationality:Date <strong>de</strong> naissance / Birth date :Points d'interet historique :Historical Field <strong>of</strong> Interest:Epoques etudiees :Period studied :Recherche actuelle :Current research :Travaux publies dans ce secteur:Published work in this field :Signature : Date :Application form to be sent in duplicate to <strong>the</strong> General Secretary:Formu<strong>la</strong>ire a renvoyer en double exemp<strong>la</strong>ire au Secretaire General:Dr A<strong>la</strong>in LELLOUCH, Hopital <strong>de</strong> Poissy, Saint-Germain-en-Laye20 Rue Armagis, 78105 Saint-Germain-en-Laye, FranceTel. : # 33-1-39 27 42 97/Fax: # 33-1-39 27 42 98e-mail: A<strong>la</strong>in.Lellouch@wanadoo.fr ou/or aajet@noos.fr160

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