<p> European Society for Blood and Marrow Transplantation</p><p>Please send the completed form to: EBMT Executive Office, Edifici Dr. Frederic Duran i Jordà Passeig Taulat, 116, 08005 Barcelona - Spain Tel: (+34) 93 453 8570 · Fax: (+34) 93 451 9583 · e-mail: [email protected]</p><p>EBMT MEMBERSHIP APPLICATION FORM Individual EBMT Patron</p><p>Please note that if you are already listed in a centre, you do not need to apply for this membership as you enjoy the same rights and privileges being in a centre as being an individual member.</p><p>Please print clearly Surname: Name : Institution: Department: Street: City: Post code: State:/Province: Country: Phone: Fax: E-mail: (compulsory)</p><p>QUALIFICATIONS: I am qualified as a……….….. Physician Nurse Other* </p><p>*Please specify: ………………………………….</p><p>I am applying from a Low-to-Middle Income country, as determined by the World Bank Group </p><p>MEMBERSHIP FEE: The annual fee is 250 euro for a physician and any other patron, and 40 euro for nurses which covers individual membership for one member. The annual fee for an LMIC member applicant is 20 euro per year (proof of employment within an LMIC is required to be submitted along with application). Please do not send cheques with your application form. Applicants will receive an invoice from the Financial Department following acceptance of their application.</p><p>SPONSORSHIP: Sponsorship by two EBMT members with Full or Associate membership is required. If you are applying as an LMIC member, please contact the membership department if you are unable to provide sponsorship, and we will assist you with this. 1st Sponsor: Name and CIC ...... Signature: ...... </p><p>2nd Sponsor: Name and CIC ...... Signature: ...... European Society for Blood and Marrow Transplantation</p><p>Please send the completed form to: EBMT Executive Office, Edifici Dr. Frederic Duran i Jordà Passeig Taulat, 116, 08005 Barcelona - Spain Tel: (+34) 93 453 8570 · Fax: (+34) 93 451 9583 · e-mail: [email protected]</p><p>COMMITMENT: By signing below, I certify that I am actively involved in the scientific and clinical area of blood or marrow transplantation (or transplantation of other haematopoietic tissue) and have worked in the field for over two years.</p><p>By signing this contract I declare that I understand and accept that my personal data will be incorporated in a file property of EBMT which can be allocated outside the EU. The EBMT will use your information only for the purposes for which you submitted the information. </p><p>The Data Subject shall have the right of access to his or her data and the right to rectification of any inaccurate or incomplete personal data. If the processing operation is unlawful the Data Subject has the right to request deletion of that data. Please write to [email protected]</p><p>Date: ...... Signature: ...... </p><p>Appendix A: BENEFITS FOR THE EBMT Individual Patrons</p><p>Individuals Patrons have the following rights and obligations:</p><p>1) Participate in activities of the Working Parties 2) Receive information about Board and other activities, co-operative studies, and results of EBMT research projects 3) Have access to the EBMT Registry and to statistical overviews of transplants (subject to current privacy regulations) 4) Be eligible for reduced fees to attend the Annual Meeting of EBMT 5) Be eligible for reduced registration fees to EBMT educational events. 6) Receive EBMT Newsletters 6 times per year 7) Access the annual results of the EBMT Transplant Activity Survey on the website (www.ebmt.org > Research > Transplant Activity Survey > Results) 8) Be eligible for an individual discount of 50% to the subscription to the Official Journal of the EBMT, Bone and Marrow Transplantation Journal. 9) Submit data for presentation at the annual meeting European Society for Blood and Marrow Transplantation</p><p>Please send the completed form to: EBMT Executive Office, Edifici Dr. Frederic Duran i Jordà Passeig Taulat, 116, 08005 Barcelona - Spain Tel: (+34) 93 453 8570 · Fax: (+34) 93 451 9583 · e-mail: [email protected]</p>