Membership application to become a:

Full member ... / Student member ... (Please select)
of the Swiss Physiological Society

Last Name
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First Name
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Birth date
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Professional address
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Postal code, City

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E-Mail
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Private address
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I am already a member of:
.... Swiss Biochemical Society
.... Swiss Society for Anatomy, Histology and Embryology
.... Swiss Society for Pharmacology and Toxicology
.... Swiss Society for Celullar biology, Molecular biology and Genetics

Other..........................................................................

Recommended by two members of the Swiss Physiological Society:


1. Last Name................................................First Name.............................................

Address.............................................

Signature...........................................


2. Last Name.................................................First Name.............................................

Address.............................................

Signature...........................................

Signature ...............................................................................Date................................

Enclosed:
1. Curriculum Vitae
2. Liste of publications
3. Copy of the student ID (for student applicants)

Send to:
Prof. Ernst Niggli
Physiologisches Institut
Universität Bern
Bühlplatz 5
CH-3012  Bern
Fax: +41 31 631 4611