Membership Questionnaire

Data type:

APPLICATION

UPDATE INFORMATION

Family name

Name

Title

Date of birth

Home address

Phone/fax/cell phone

E-mail

Clinic address

Phone/fax/cell phone/e-mail

Are you a member of CZMA JEP:

Yes

No

Are you interested to work in concerns:

Yes

No

Do you have any requests or comments on the GP´s work:

Yes

No

Are you interested in the working group:

Yes

No

Are you interested about clinical days with these comments:

Yes

No

Delete all Send

Společnost všeobecného lékařství ČLS JEP