SCHEDA DI ADESIONE ALLA

               (Form to belong at the)

"Commissione Etica Internazionale Scientifica - Medica - Farmaceutica"

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             Dati del Componente

                (Member's data)

                  Cognome…………………………………………………………………………………

                 (Last name)

                   Nome….…………………………………………………………………………………

                (First name)

                   Anno di Laurea                   Diploma                       Specializzazione..…………………

                 (Degree)                                 (Diploma)                        (Specialities)

                Codice Fiscale……………………………………..Partita IVA..………………………

                 (Fiscal code)                                                                   (VAT)

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                1.-Indirizzo abitazione

                   (Home address)

                    Via………………………………………………………………………………………

                (Street)

                    CAP…………………….Città……………………Provincia………Nazione…………

                (Zip)                                 (City)                                  (Province)             (Nation)

                    Telefono……………….. Fax………………….….e-mail……………………………..

                      (Telephone)

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                      2.-Indirizzo studio      Università       IRCCS       Az. Ospedaliera      A.S.L.      Ente

                       (Address office)           (University)                             (Hospital)                               (Corporation)

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                      Via..…………………………………………………………………………………….

                (Street)

                  CAP…………………………Città……………….Provincia………Nazione.…..…….

               (Zip)                                            (City)                           (Province)            (Nation)

                  Telefono……………………..Fax…………………………e-mail.……………………

                (Telephone)

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   Indirízzo dí spedizione     CORRISPONDENZA   1          2  

   (Forwarding address)          (Incoming  mail)

                                      Data………………………………                                    Firma………………………

                (Date)                                                                                      (Signature)