GREAT that you are considering to collaborate!
Do you want to spend your holidays usefully? Do you also want to go back to basics with your knowledge?
Then fill out the form below!

Full name: *

Birth date + place: *

Street: *

Postal code: *

City: *

Phone + fax.: *

Email: *

Nationality: *

Gender: *

M

F

Professionally active : *

Yes

No

If yes, since what year have you been active professionally without interruption? :

Work address mandatory if you're professionnaly active

Name of hospital or private practice :

Street:

Postal code:

City:

Phone + fax.:

Email:

Work experience:

Professional information

Qualifications: *

Specialisation: *

Sub specialisation:

Tropical Medicine?:

Yes

No

Experience in development countries?:

Yes

No

Where? Name of organization? Period?...:

Language Knowledge

French: *

moderate

Good

English: *

moderate

Good

Other:

Questions or remarks:

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