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Application for Registration as a
European Specialist in Clinical Chemistry and Laboratory Medicine (EurClinChem)

Please fill in in the online application form. After clicking the application button, a printable version of this form containing your data will be generated. Please print it and follow the instructions at the top of the printed page.

Here you can look up the address of your National Clinical Chemistry Registration Commitee.


1. Personal Details of Applicant

Please do not write any data in capitalized letters (INSTITUTE OF CLINCHEM --> Institute of ClinChem, PARIS --> Paris)

  

Title Academic title, e.g.:
" Prof. Dr.", "Dr.", "Dr. rer. nat."
(not "Pharmacien", "Biologiste",..)
* First Name "David", "Sarah"
Middle Initials "M.", "William"
* Last Name "Smith"
Institution, Company

"Hospital de Santo António"
"Université de Paris"
"Laboratoire Medicale B&P"
Department "Central Laboratory"
" Institut für Klinische Chemie"
* Sex   male        female (please select)
* Date of birth   (please select)
* Street

"1, Avenue Charles de Gaulle"
"Königsberger Str. 34"
* Postcode, City
"75016 Paris"
" NR18 0PD Wymondham"
" 30001 Hannover"
* Nationality (please select)
* Country of Residence (please select)
* Telephone Country code "+49"; "+33"
* Telephone

Including area code (without zero)
"441-358674", "9-32-1920-89"
Fax Including area code (without zero)
" 441-358674"; "4432-1920-89"
* E-Mail "david.williams@clinical-lab.com"


2. Personal Declaration

Acceptance of the conditions of the EC4 Register is essential for all who seek to join it.You should read the following statement and then sign it to indicate that you understand it and will abide by it:

" I hereby apply to be registered as a European Specialist in Clinical Chemistry and Laboratory Medicine. In making this application I affirm that:

  • I have read and understood the 'Guide to the EC4 Register' and the accompanying syllabus
  • I consider my training to meet the minimum standards in the 'Guide to the EC4 Register'.
  • I consider that I am competent to practise as specified in the 'Guide to the EC4 Register'
  • I shall abide by the EC4 Code of Conduct."

 

*  I accept the declaration   


3. Finance

The application fee is 50.00 EUR. This fee is non-returnable. If your application is accepted, this fee will also cover registration for a period of five years.

*  

I will transfer 50.00 EUR to the EC4 bank account no.: 515995231
ABN AMRO BANK, PO Box 2059, 3500 Utrecht, The Netherlands
BIC: ABNANL2A
IBAN: NL34ABNA0515995231

Cheque and credit card payment can not be accepted.

* = mandatory fields

Please verify your data and click the button:

 

By clicking the button, you agree that EC4 stores your personal data for internal purposes.
These data will not be given to third parties.

Your data will be transmitted to EC4 in SSL encrypted form.

After having received your data, you will see a membership form
with your personal data in HTML file format.
Please print it out and follow the instructions in the file.