SINS Società Italiana Di Neuroscienze

SINS – Italian Society for Neuroscience

MEMBERSHIP APPLICATION FORM A. PREDOCTORAL OR STUDENT MEMBER INFORMATION Last Name………………………………………………………………………………………...... First Name….………………………………………………………………………………..……..... Tax ID number ……………………………………………………………………………...... Professional role …………………………………………………………………...……..………..... Company/Institution ……………………………………………………………………...…….…..… …………………………………………………………………………………………………………

 Business mailing address …………………………………………………..………...... ………………………………………………………………………………………………… Telephone …………..…..………..………...... Fax …………………..…………………… E-mail ………….……………………………..…………..………………………………..…

 Home mailing address .……..……………………………………………...……………...... ………………………………………………………………………………………………… Telephone …...... ………..…..………..…… Fax …………………..…………….……… E-mail ………….……………………………..…………..………………………….……..… Date ……/……/…… Signature ……………...………………………......

Note. Please check the box next to the address to be used for correspondence Please attach the following documents: 1. a brief curriculum vitae (maximum one page) 2. a presentation letter of one of your presenter 3. a list of 5 keywords related to your scientific competencies

RECOMMENDATION GIVEN BY 1) Full Name …..………………………………… Signature …………...... ……………………… 2) Full Name……………………………………....Signature………... ……………………...... Privacy and Confidentiality Pursuant to Law n. 675 of December 31, 1996, concerning the “Data protection rights of individuals and other entities”, I hereby authorize the Italian Society for Neuroscience (SINS) , in the person of its pro-tempore Secretary/Treasurer, to process my personal data solely for purposes related to the Society’s activities and to the extent and scope necessary to fulfill such purposes. O Yes, I give my consent O No, I don’t give my consent

Date ……/……/…… Signature …………………..…………………………………....