Personal details of applicant

□ Mr   □ Mrs   □ Miss   □ Ms   □Dr   □ Assist Prof  □ Assoc Prof  □ Prof

Gender  □ Male    □ Female               Date of Birth   //      //     //      //      ( day/month/year) 

Name ( last,first, middle intitial) :       

Mailing Address – indicate Home / Hospital/ University/ Private Practice/ Firm/Corporation

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I am a :   □ Cardiologist □ Physician □  Geriatrician   □ Family Doctor □ Cardiac Surgeon 

               □  Epidemiologist   □ Pharmacologist   □ Pharmacist   □ Nurse/Nurse Practitioner

               □  Scientist    □ Technician   □ Other Health Professional   □ Industry Professional 

Main Fields of Interest   □ Diagnostic Techniques  □ Drug Therapy   □ Non-pharmacologic Management  

□ Epidemiology and Prognosis  □ Congenital Disease   □ Prevention  □ Experimental Heart Failure   □ Cardiac Function/ Hemodynamics   □ Nursing and Multidisciplinary Heart Failure Management    □ Other : …………………………….

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Signature

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Please return the above completed membership form by fax to +31-10-4854833

at  the attention of Mrs P.Illingworth or e-mail to secretariat@sticares.org

No Fees Required