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

**Registration form** 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
Application supported by a member of the MIM
	Enter secure code

The above information will be used exclusively for purposes directly related to MIM activities.

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.

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

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