Membership Form

Application Type

	New Member
	Renewal

Membership Type

	Members - €40
	Interns, Residents, PhD students - €20
	Technicians, nurses - €20

Personal Details

Name
Degree
Home Address
Country
Phone
Email
Password

Clinic/Business Details

Clinic Name

Address

Country

Phone

Email

I wish my VWHA information to be sent to:

	Home Address
	Office Address

Degree/Title:

Other:

Field of Work:

Type of Work:

Other:

Board Certification:

	Yes
Which field: