I, ……………………………………………………………………………………………………..(name in capital letters),
Address for correspondence Street and Number:………………………………………………………………
Postcode and City:……………………………………………………………….
Telephone:…………………………………………………………………………..
E-mail:…………………………………………………………………………………
practicing colorectal surgery in the following hospital(s):……………………………………………………
……………………………………………………………………………………………………………………(name and city)
Officially confirm my candidature for (please, indicate your choice)
- Full member (can be Full member of the Section, the surgeon who is member of thePractices surgery in Belgium, has more than 50% of his activity devoted to colorectal
- Surgery or is largely renowned as an expert in colorectal surgery
- Royal Belgian Society for Surgery (titular, corresponding or ordinary member),
- Ordinary member (can be Ordinary member of the Section, the surgeon who is member of the
- Royal Belgian Society for Surgery (titular, corresponding or ordinary member), practices surgery in Belgium, has an interest in colorectal surgery
- Associate member (can be Associate member of the Section a non-surgeon with special interest in colorectal disease)
- Honorary member (can be Honorary member of the Section anyone considered to have
- Made an outstanding contribution to the field of colorectal diseases)
- Corporate member (can be Corporate member of the Section any member of a company
- Or organization with an interest in colorectal disease)
I am interested in becoming a Board member of the Section (full membership is necessary)
- Yes
- No
- Names of 2 colleagues Full members, who are prepared to act as referee supporting my candidature
- ……………………………………………………………………………………………………..(name, hospital and city)
- ……………………………………………………………………………………………………..(name, hospital and city)
Email : info@acta-medica-belgica.be
Fax : 02/374.96.28
Send to : Belgian Section of ColoRectal Surgery
C/o RBSS
avenue W.Churchill laan 11/30
1180 BRUSSELS