Application form Candidate Toxicologist
Netherlands Society of Toxicology
REGISTRATION COMMITTEE TOXICOLOGY
Application for registration as Candidate Toxicologist
Last Name:
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M/V
First name and initials:
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Date and place of birth:
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Home address:
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E-mail address:
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Institution/company:
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Job:
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Work address:
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Please send all correspondence to:
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Home address
Work address
This application for registration as a Candidate Toxicologist has been submitted by:
Supervisor:
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Training faculty:
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General
The supervisor submits the application on behalf of the Training faculty to the Registration Committee.
Please, send in triplicate the application form and the appendices by mail to:
Frans Koeman
Registration Committee Toxicology
c/o Office KNCV
P.O. Box 249
2260 AE Leidschendam
Or by email to: regnvt@kncv.nl
August 2012
Application form Candidate Toxicologist
Education
Master:
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Major:
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Minor(s):
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University/College:
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Research /work:
a) Experience
To apply for registration as a research toxicologist (Besluit 1) an abstract of your PhD research must be
submitted.
To apply for registration as an applied toxicologist (Besluit 2) a description of your present job and
your activities in the field of applied toxicology must be submitted.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------b) In training since/active in current field since: -----------------------------------------------c) Name and address of Institution/Employer: --------------------------------------------------------------------------------------------------------------------------------------------------List of publications:
1. ---------------------------------------------------------------------------------------------------------2. ---------------------------------------------------------------------------------------------------------3. ---------------------------------------------------------------------------------------------------------4. ---------------------------------------------------------------------------------------------------------(Please, supply additional publications as an appendix)
Appendices to be submitted:
1. Completed survey of compulsory/mandatory courses and of optional courses of the Postgraduate
Education in Toxicology. (Please, remember enclosing photocopies of your diplomas).
2. CV
Date:
Administratieadres: p/a KNCV, Postbus 249, 2260 AE Leidschendam, tel.: 070 33 78 790, fax: 070 33 78 799
e-mail: regnvt@kncv.nl, ABN-AMRO rekeningnummer 48.90.96.875, IBAN NL59ABNA0489096875, BIC ABNANL 2A
Appendix 1: Survey PET Courses
Signature Supervisor
Signature Applicant
Date
Information
A. Compulsory/mandatory courses PET
1. General Toxicology
2. Molecular Toxicology
3. Cell Toxicology
4. Pathobiology
5. Organ Toxicology
6. Introduction Laboratory Animal Science
7. Epidemiology
8. Ecotoxicology
9. Risk Assessment
B. Optional courses
Choose at least three of the following courses from the POT program
1. Medical and Forensic Toxicology
2. Occupational Toxicology
3. Food Toxicology
4. Immunotoxicology
5. Reproduction Toxicology
6. Mutagenesis and Carcinogenesis
7. Toxicogenomics
8. Risk Communication
9. Regulatory Toxicology
Research experience:
Option1: ≥ Four publications and a
dissertation
Or
Option 2: Broad experience of at
least four years in one or more of
the following fields:
1.
Risk Evaluation and policy
advice on chemicals
2.
Regulatory Toxicology
3.
Food toxicology
4.
Veterinary Toxicology
5
Drug Toxicology
6.
Occupational Toxicology
7.
Environmental Health
8.
Ecotoxicology
9.
Forensic and medical
Toxicology (medical,
analytical)
10. Toxicological Pathology
Education (Decision 5)
Completed Master in medical,
biological, veterinary, biochemical
or pharmaceutical area
PET: Postdoctoral Education in Toxicology
Please, remember enclosing photocopies of your diplomas