University cluster membership

Please complete this form to submit your request for membership of EPSO. Once complete, you can also fax (+32-2-213-6269) or mail (European Plant Science Organisation, EPSO, Rue de l’ Industrie 4, 1000 Brussels, Belgium) this form after printing.

Our organisations would like to join EPSO as a university cluster:

Organisation 5

Original name:

Please enter the name of the organisation as it is commonally referred to

Name in English:

Please enter the organisation's name in English, if different from above

Street:

City:

Country:

Telephone:

Fax:

Website:

Approx. number of staff:

Including technical and scientific people, excluding undergraduate students

Scope and expertise:

E.g. university, research institute, organisation facilitating research; scientific expertise - ecology, physiology, molecular biology etc.

Representative of the organisation for EPSO

Name:

Representative's address:

If different from organisation's address

Telephone of representative:

If different from organisation's telephone number

Representative's e-mail:

Function in the institute:

Function in the university:

Science expertise:

Supporting Scientist

Name of supporting scientist:

Supporting scientistic's address:

If different from organisation's address

Telephone of supporting scientist:

If different from organisation's telephone number

Supporting scientist's email:

Function in the institute:

Function in the university:

Science expertise:

Organisation 3

Original name:

Please enter the name of the organisation as it is commonally referred to

Name in English:

Please enter the organisation's name in English, if different from above

Street:

City:

Country:

Telephone:

Fax:

Website:

Approx. number of staff:

Including technical and scientific people, excluding undergraduate students

Scope and expertise:

E.g. university, research institute, organisation facilitating research; scientific expertise - ecology, physiology, molecular biology etc.

Representative of the organisation for EPSO

Name:

Representative's address:

If different from organisation's address

Telephone of representative:

If different from organisation's telephone number

Representative's e-mail:

Function in the institute:

Function in the university:

Science expertise:

Supporting Scientist

Name of supporting scientist:

Supporting scientistic's address:

If different from organisation's address

Telephone of supporting scientist:

If different from organisation's telephone number

Supporting scientist's email:

Function in the institute:

Function in the university:

Science expertise:

Organisation 4

Original name:

Please enter the name of the organisation as it is commonally referred to

Name in English:

Please enter the organisation's name in English, if different from above

Street:

City:

Country:

Telephone:

Fax:

Website:

Approx. number of staff:

Including technical and scientific people, excluding undergraduate students

Scope and expertise:

E.g. university, research institute, organisation facilitating research; scientific expertise - ecology, physiology, molecular biology etc.

Representative of the organisation for EPSO

Name:

Representative's address:

If different from organisation's address

Telephone of representative:

If different from organisation's telephone number

Representative's e-mail:

Function in the institute:

Function in the university:

Science expertise:

Supporting Scientist

Name of supporting scientist:

Supporting scientistic's address:

If different from organisation's address

Telephone of supporting scientist:

If different from organisation's telephone number

Supporting scientist's email:

Function in the institute:

Function in the university:

Science expertise:

Organisation 2

Original name:

Please enter the name of the organisation as it is commonally referred to

Name in English:

Please enter the organisation's name in English, if different from above

Street:

City:

Country:

Telephone:

Fax:

Website:

Approx. number of staff:

Including technical and scientific people, excluding undergraduate students

Scope and expertise:

E.g. university, research institute, organisation facilitating research; scientific expertise - ecology, physiology, molecular biology etc.

Representative of the organisation for EPSO

Name:

Representative's address:

If different from organisation's address

Telephone of representative:

If different from organisation's telephone number

Representative's e-mail:

Function in the institute:

Function in the university:

Science expertise:

Supporting Scientist

Name of supporting scientist:

Supporting scientistic's address:

If different from organisation's address

Telephone of supporting scientist:

If different from organisation's telephone number

Supporting scientist's email:

Function in the institute:

Function in the university:

Science expertise:

Organisation 1

Original name: *

Please enter the name of the organisation as it is commonally referred to

Name in English:

Please enter the organisation's name in English, if different from above

Street: *

City: *

Country: *

Telephone: *

Fax:

Website:

Approx. number of staff:

Including technical and scientific people, excluding undergraduate students

Scope and expertise:

E.g. university, research institute, organisation facilitating research; scientific expertise - ecology, physiology, molecular biology etc.

Representative of the organisation for EPSO

Name:

Representative's address:

If different from organisation's address

Telephone of representative:

If different from organisation's telephone number

Representative's e-mail:

Function in the institute:

Function in the university:

Science expertise:

Supporting Scientist

Name of supporting scientist:

Supporting scientistic's address:

If different from organisation's address

Telephone of supporting scientist:

If different from organisation's telephone number

Supporting scientist's email:

Function in the institute:

Function in the university:

Science expertise:

Other comments:

Completed by: *

Date: *

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