BELGISCHE VERENIGING VOOR MEDISCHE INFORMATICA V.Z.W. MIM SOCIETE BELGE D'INFORMATIQUE MEDICALE A.S.B.L.

Application form to the " MIM",
the Belgian Medical Informatics Association

version 2.2

First name
Last name
Title
Date of birth
Institution
Postal mail address for MIM documents
postcode: -, city:
Telephone
FAX
Email
Website
Summary of Curriculum vitae
Interests
Interest in a specific Virtual Working Group
Application supported by a member of the MIM

Participation for individuals is 60 Euros, 30 Euros for students and retired members.
Companies may also register, send 3 delegates for a participation of 200 Euros.
You will be invoiced later.

Please fill in this form, submit or print it on paper and send per post or Fax to the secretary :
Secretary :
Philippe PIETTE
rue Bon Air 2
1470 Baisy-Thy
Belgium
tel + 32_71287038 or +_32_67773880
p.piette@hopitaux-gilly.be

Your application will be proposed at the next meeting of the board.