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APPLICATION FORM FOR ASSOCIATE MEMBERSHIP IN EPSA

EPSA Terms of Reference state: Article 8.4 Any pharmaceutical students association that does not fulfill the criteria for Ordinary Membership shall be eligible to apply for Associate Membership

THE APPLYING ORGANISATION:


Name Permanent address Telephone Email address Fax

*Publication of the Organisation


Name Permanent address N of issues per year

CONTACT PERSONS:
President

Address

Secretary

Address

Treasurer

Address

Liaison Secretary for EPSA

Address

DETAILS ABOUT THE ORGANISATION: Number of pharmaceutical students represented by the organisation Number of pharmaceutical students in the member country Number of Schools of Pharmacy in the member country How many of these are represented by the organisation? How is the work within the organisation organised:

The General Assembly of the organisation is held:

PLEASE ENCLOSE THE FOLLOWING: - Your statutes and internal regulations in English and in your mother tongue. - List of the Schools of Pharmacy and their addresses. (State those which are represented by national organisation). - An independent reference confirming the information submitted in the application (e.g. Dean of the faculty). - The organisations estimated yearly budget in Euros. - Information concerning former membership in EPSA.

The undersigned hereby submit an application to become Associate Member of the European Pharmaceutical Students' Association. We certify that the information given is correct. The undersigned has read and understood the Terms of Reference and Standing Orders of EPSA promise to adhere to them.

Signed:

President Signature: ______________________________________________________

Treasurer Signature: ______________________________________________________

Secretary Signature: ______________________________________________________

Official stamp of organisation/faculty

Place:

Date: