Euprera - Application form

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Choose password:*
Membership category:*	Individual Institution
Title:*
First name:*
Last name:*
Institution:*
Department:*
Activity:*	Academic Education Professional Training Other
(WHEN "EDUCATION" is selected) Short presentation of your institution (to be published in "EduInfo" if your application is accepted):*
Area of interests:* (Select multiple items by pressing CTRL (PC) or Command (Mac) while clicking)
Phone Number:
Email Address:*
Address 1*
Address 2:
Postal code:*
City:*
Country:*
Why do you want to join EUPRERA:*
Have you been recommended by a Euprera member?*	Yes No
By whom?
By agreeing to become a member (or an institutional member) of EUPRERA, you (and everyone who is named in your institutional membership) are also agreeing to work with the wider membership, to abide by and uphold EUPRERA's aims and objectives. If at any time you (or a member named as being part of your institutional group) publish or behave in any way that the EUPRERA Board deems to be contrary to its stated aims and objectives, your membership can be immediately revoked.
* Required.	I AGREE


In case you wouldn't get any response you should contact the DPRA: dpra@euprera.org


	How to use this form
	For new members You can use this form to apply for either Institutional or Individual membership. If you are applying for Institutional membership fill in the form with your own personal details; you will then have the opportunity to fill in a similar form for each of your colleagues. Don't forget to add your website address when presenting your institution. For current members If you are a member but never registred to the website, please fill in this form with your personal data. If your membership is Institutional, fill in the form with your own personal details; you will then have the opportunity to fill in a similar form for each of your colleagues.

Euprera
Bd du Jubilé 71, bte 3
1080 Brussels
Belgium
VAT code 0478953039

info@euprera.org