Application Form for a Committee S Member Position

Scientific Division (SD)

APPLICATION FORM FOR A COMMITTEE’S MEMBER POSITION

Committee on “Traceability in Laboratory Medicine (C-TLM)”

National Society/Corporate Member:

Last name:

First name:

Date of birth:

Current professional position:

 Academic

 Hospital

 Industry

 Other (please specify)

Current institutional positions :

 National and International Scientific Societies

 Official Institutions and Bodies

1 Scientific Division (SD)

Curriculum Vitae

. Academic qualifications:

. Professional titles:

. Institutional positions :

. Positions in National and International Scientific Societies:

. Others:

Special expertise in the topic to be investigated by the Committee (no more than 250 words):

2 Scientific Division (SD)

List of publications and communications in the topic:

. References in peer-reviewed (PubMed) journals:

. Other journals:

. Invited presentations to International Congresses:

. Organization of meetings:

. Education activities:

Any other useful information (no more than 50 words):

Letter of support of the National Society (please attach a copy):

Date: Signature: