Register for BSC membership

Contact Details

Title*: Dr.Prof.Mr.Mrs.Ms.
First Name*:
Last Name*:
Date of Birth*:
Email*:
ESC ID number:

Work Address

Organisation/Institution Name*:
Line 1*:
Line 2:
City*:
Postcode*:
Country*:
Telephone:
Mobile:

Home Address

Line 1*:
Line 2:
City*:
Postcode*:
Country*:
Telephone:

Cardiologist applicants need to indicate their RIZIV/INAMI number.
The other categories of applicants need to be supported by one BSC member (for Junior applications, this is the internship supervisor).

I am applying for membership as a*: CardiologistJunior CardiologistParamedicSubject Matter ExpertScientist

[group Cardiologist]
RIZIV/INAMI number*:
[/group]
[group junior-cardiologist]
RIZIV/INAMI number:
[/group]

[group referee]

BSC Member Referee

First Name*:
Last Name*:
Hospital/Organisation*:
Email*:
[/group]

[group junior-cardiologist]
CV*:
What is the start date of your training*
What is the expected end of your training*
[/group]

I am interested in the following Working Groups and Councils*:BeHRABelgian Council on CardiogenomicsBelgian Council on Cardio-OncologyBIWACBWGACHDBWGBRCBWGCVNBWGHFBWGICBWGNICIBWGPCYCC

I consent to the BSC using my details for the purposes of registration, membership communications and other purposes as defined in the Privacy Policy*

[group referee]I acknowledge that it is my responsibility to ask the referee to send an email to the BSC confirming my application*[/group]