<p> Scientific Division (SD)</p><p>APPLICATION FORM FOR A COMMITTEE’S MEMBER POSITION</p><p>Committee on “Traceability in Laboratory Medicine (C-TLM)”</p><p>National Society/Corporate Member: </p><p>Last name: </p><p>First name: </p><p>Date of birth: </p><p>Current professional position: </p><p> Academic </p><p> Hospital</p><p> Industry</p><p> Other (please specify)</p><p>Current institutional positions : </p><p> National and International Scientific Societies</p><p> Official Institutions and Bodies</p><p>1 Scientific Division (SD)</p><p>Curriculum Vitae</p><p>. Academic qualifications: </p><p>. Professional titles:</p><p>. Institutional positions :</p><p>. Positions in National and International Scientific Societies:</p><p>. Others:</p><p>Special expertise in the topic to be investigated by the Committee (no more than 250 words):</p><p>2 Scientific Division (SD)</p><p>List of publications and communications in the topic:</p><p>. References in peer-reviewed (PubMed) journals:</p><p>. Other journals: </p><p>. Invited presentations to International Congresses:</p><p>. Organization of meetings:</p><p>. Education activities:</p><p>Any other useful information (no more than 50 words):</p><p>Letter of support of the National Society (please attach a copy):</p><p>Date: Signature: </p><p>3</p>