Application for Membership
Hereby I
surname:
..........................
.....
first name:
...............
born:
.
..............................
nationality
...............
home address
Road:
.
Postal zip code:
.
Residence:
.
Phone:
.
Fax:
.
e-mail
.
office address
Road:
.
Postal zip code:
.
Residence:
.
Phone:
.
Fax:
.
e-mail
.
apply for
full/associate membership to EHPGBM e.V.
(Please delete where not applicable.)
I confirm
that I am licenced to work as naturopath. Yes/No
(Please delete where not applicable.)
I am
working in own office/joint practice.
(Please delete where not applicable.)
I am
belonging to the following association ...........
...................................
I am
treating with the following equipment
MORA 3o.4 q MORA-SUPER q Bicom
q others
.......................
.....................
The
membership fee amounts to 96 per year for full and associate members.
I assure
the correctness of the informations stated before.
The
remittance fee for the member fee has to be carried by the membetr. The
remitance has to be free of charges for the addressee.
Date
....................................................................
subscription/stamp of office
