Application Form Group Membership

National societies, groups or federations which represent the interests of gastroenterology and endoscopy nurses and endoscopy associates based in a geographic European country.
To prevent undue dominance of countries with several national groups, each internationally recognised European country has the right to cast one vote, regardless of the number of group memberships a European country possesses.
Username*

Please choose a username which you will need to log into the Members Area once your application has been approved. Please be aware that your username cannot be changed once chosen.
Password*
Enter Password Confirm Password
Society Address
Name of Society*
Abbreviation*
of Name
Address*
Street Address ZIP / Postal Code City Country
Email*
Phone*
Fax*
Website
Total number of members*
Qualification of members*
President of Society
Female/Male*
- Female
- Male
Title*
First Name*
Family Name*
Email*
Contact Person
- should be able to communicate in Englisch
- will receive all information from ESGENA with the request to communicate the information within the national society and/or within country
- will receive the ESGENA E-News for distribution among members of the national society
- is responsible for all contact updates
Female/Male*
- Female
- Male
Title*
First Name*
Family Name*
Email*
Address*
Street Address ZIP / Postal Code City Country
Phone*
[Country Code/Area Code/Phone Number]
Hospital Address Contact Person (Employer)
Hospital name*
Department*
Position*
Address*
Street Address ZIP / Postal Code City Country
Hospital Email

[only personalized by hospital]
Phone
[Country Code-Area Code-Phone Number]
Billing Address
Name of Society*
Female/Male*
- Female
- Male
Title*
First Name*
Family Name*
Email*
Address*
Street Address ZIP / Postal Code City Country
Phone
[Country Code/Area Code/Phone Number]
Data Release
Please note that with your data release, ESGENA is allowed to use your email addresses for the mailings of ESGENA membership issues, the ESGENA e-Newsletter, conference announcements and further educational activities relevant for ESGENA. ESGENA will not share your contact details with third parties.
Date of Data Release*
DD dot MM dot YYYY
Privacy*
- I have read the ESGENA Privacy Policy and agree to the terms & conditions.

Society Address

President of Society

Contact Person

Hospital Address Contact Person (Employer)

Billing Address

Data Release