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AATM Application Form Arm

AATM Application Form Eng

AATM Application Form Rus

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Select membership category: Regular-Student / Junior / Institutional-Corporate

Application Form for Regular / Student

Title	Dr. Mr. Mrs. Ms. Other
First Name*
Last Name*
Sex	Male Famale
Date of Birth*	day / month / year
Position
Department
Organization*	Company Institution High School University
Address, line 1*
Address, line 2
City*
Postal Code*
Country*	Other Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Australia Austria Azerbaijan Bahrain Baker Island Bangladesh Barbados Bassas da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia Gabon Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City) Honduras Hong Kong (SAR) Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnston Atoll Jordan Juan de Nova Island Kazakhstan Kenya Kingman Reef Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Man, Isle of Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Midway Islands Miscellaneous (French) Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Helena Saint Kitts and Nevis Saint Lucia Samoa San Marino Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Virgin Islands (UK) Virgin Islands (US) Wake Island Wallis and Futuna West Bank Western Sahara Western Samoa World Yemen Yugoslavia Zaire Zambia Zimbabwe
Phone*	+
Fax	+
E-mail*
Employment*	Government Academic Non-profit Industry Student Retired Other
Education*	Primary Secondary Higher Postgraduate Advanced or Degree
Specialty / Field of Practice*	Medicine Other health care ICT Other
Referrers*
First Name*
Last Name*
Interests in the field of Telemedicine and eHealth
Business and Finance	Distance Learning & CME
Electronic Patients' Management	Home Telehealth & Remote Monitoring
Hospital Information Systems	International
Technology	Teledermatology
Telehealth Nursing	Telemental Health
Teleophthalmology	Telerehabilitation
Telesurgery	Telepathology
Pediatric Telehealth	TeleICU
Enter what you see
I hereby authenticate that I have read, understood and accepted the Bylaws of AATM; I give my consent to fully comply with the decisions of the Board of Directors of AATM, or any other regulating / supervising body thereof, including obligation to duly pay entrance and membership fees, special assessments or any other charges established by the Board; I realize that failure to comply with the decisions of the Board of Directors, to properly perform and timely complete the duties and any specific tasks assigned to me by the Association’s regulating / supervising bodies, and/or to duly pay entrance and membership fees, special assessments or any other charges established by the Board, may result in termination of my membership.