European Society for translational
Antiviral Research
Application form for membership
1. Personal details
Title
:
First name (s)
:
Last name (s)
:
Gender
:
Nationality
:
Institute
:
Department
:
Street
:
Postal Code
:
City
:
MD
PhD
Male
Female
Msc
Other …..
Country of residence :
E-mail
:
Phone number
:
ESAR Office
Attn: Mrs A. van Kessel
UMC Utrecht
Dept. of Virology G04.614
Heidelberglaan 100
3584CX Utrecht
The Netherlands
phone: +31-88-755 6526
fax: +31-88-755 5426
info@esar-society.eu
www.esar-society.eu
Bank details
Rabobank Utrecht
Maliebaan 15
3581CB Utrecht
The Netherlands
NL43 RABO 0101254962
BIC: RABONL2U
Chamber of Commerce: 51362899
2. Membership types
Membership of ESAR is individual and not based on institute or company representation.
The annual membership fee for 2014/2015 will be 10 Euro for all members. After the
application form is received by the ESAR Office an invoice for membership fee will be sent to
you.
Please select a membership type
o Associated member
Scientists should prove their scientific commitment by authorship on a publication on a
virological subject in a peer reviewed journal. Clinicians should be able to show a medical
doctors degree. All associated members should be employed by non-commercial institute or
hospital for at least 50% FTE.
o Non-Associated member
Scientists should prove their scientific commitment by authorship on a publication on a
virological subject in a peer reviewed journal. Clinicians should be able to show a medical
doctors degree.
o Student member
A letter from the University/Hospital indicating the status as PhD student or Resident is
needed for registration.
3. Electronic newsletter
You will be added to the ESAR mailing list. In case you would also like to receive the ESAR
newsletter please indicate:
I want to receive the electronic newsletter.
Instructions
After completing the registration form, you can submit the form to Antoinet van Kessel either
by email to info@esar-society.eu or by fax to +31 88 755 5426.
ESAR Office
Attn: Mrs A. van Kessel
UMC Utrecht
Dept. of Virology G04.614
Heidelberglaan 100
3584CX Utrecht
The Netherlands
phone: +31-88-755 6526
fax: +31-88-755 5426
info@esar-society.eu
www.esar-society.eu
Bank details
Rabobank Utrecht
Maliebaan 15
3581CB Utrecht
The Netherlands
NL43 RABO 0101254962
BIC: RABONL2U
Chamber of Commerce: 51362899