New Member Application Form
Please complete this application form if you wish to become BVN-SBN member
Name: *
Email: *
Date of birth: *
Month / Day / Year
MM
/
DD
/
YYYY
Home address:
ZIP-code:
City:
Hospital: *
Hospital Service: *
Language:
RIZIV number: *
University grade:
Year of achieved grade:
My application is supported by 2 BVN-SBN members: *
Date: *
MM
/
DD
/
YYYY
Membership: *
Required
Confirmation - I would like to receive further information related to your society via: *
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