Registration form

Personal information

Gender*

Male
Female
X
N/A

Title

Initials*

First name*

Prefix

(e.g. van der)

Surname*

Suffix title

Date of birth*

Date of birth is required for registration as new member in the administration.

(mm/dd/yyyy)

Contact information

Home Address*

Only private address (no company or university address)

ZIP codeNumberAddition

StreetTownCountry

Email address*

Telephone number*

(06-xxxxxxxx)

Study data (if applicable)

Student*

(not PhD student)

University

Start date

(mm/dd/yyyy)

(Expected) Graduation date

(mm/dd/yyyy)

Password*

To confirm your password, please retype it below.

Statement of agreement

I attest to the accuracy of the information on the application. I understand that membership dues are payable annually unless my signed resignation is received by the administration of the society before December 1st.*