Formulaire d'adhésion - Association des Internes en Hématologie

Prénom *
Nom *
Date de naissance *
Numéro de télèphone *
Custom
Email *
Email
Adresse postale *
Street AddressApt, Suite, Bldg. (optional)VilleState / Province / RegionPostal / Zip CodePays
Identifiant de connexion *
Mot de passe *
Carte étudiante | Certificat de scolarité *
No file uploaded.
Type d'adhésion *
Adhérent(e) Interne
Est ce que vous souhaitez devenir adhérent de l'IFM (myélome) ? *
Pas de surcoût, offert avec l'adhésion de l'AIH
Est ce que vous souhaitez devenir adhérent du FIM (syndrome myéloprolifératif) ? *
Pas de surcoût, offert avec l'adhésion de l'AIH
Êtes vous en phase socle ? *
Politique de confidentialité *
En soumettant ce formulaire, vous acceptez que vos données personnelles soient recueillies et conservées en vue de tenir à jour notre fichier adhérent.
Souhaitez vous un accès à la revue Correspondance en Onco-Hématologie *
Oui
Non

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