Application for junior membership

Mitgliederantrag JM

Form of address*

Title

Surname*

First name*

Date of birth*

Language*

Nationality*

Current employment including location*

State examination

Place

Year

Basic examination

Year*

Swiss specialist doctor title or recognised foreign specialist doctor title (if already awarded)

Specialist doctor title

Year

Further training

Correspondence*

Private address

Address

Postcode

Town/City

Country

Telephone

Mobile

Website

Business address

Institution

Department

Position

Address

Postcode

Town/City

Country

Telephone

Mobile

Website

Referees

Referee 1

First name*

Surname*

Institution*

Referee 2

First name*

Surname*

Institution*

Comments

Attachments (to be uploaded)

Photo*

CV*

1. Letter of recommendation*

2. Letter of recommendation*

Confirmation of details*

I hereby confirm that the information I have provided is correct and complete and I acknowledge that the application must be submitted by 31 July at the latest.