EAPD

Personal Information

Title*

Lastname* Please type in capitalised form (John)

Firstname* Please type in capitalised form (John)

Gender

Birth Date

E-mail*

Password*

Corresponding Address

Zip

City

Country

Institution (if you work in a State establishment)

Is the corresponding address your Institutional address?

Institutional Address

Corresponding Address

Zip

City

Country

Year joined EAPD*

Phone (office)

Phone (mobile)

Fax

University and Director of the Post Grad Program

University*

Director*

Director's email*

Date of Program completion

Month

Year

Please provide 2 members of the EAPD that support your application

Member 1

Member 2

In order to complete your application process please email to the EAPD Secretary, Assoc. Prof. Sotiria Gizani at secretary@eapd.eu a letter from the University or from the Head of the program you attend stating the following information (in English):

you are student for the paediatric dentistry program,
when you started the program and
when you expect to complete it.

EUROPEAN ACADEMY OF PAEDIATRIC DENTISTRY

STUDENT MEMBERSHIP DATA FORM