Membership Request Form

Fill this form to request your membership as an effective MITO member.
In order for the request to be validated, it is necessary to enter the name of 2 already MITO members who will be contacted for confirmation.
The membership request will be evaluated during the next meeting of the MITO Board of Directors.
Acceptance of membership will be communicated by e-mail to provided address .

After submitting the form, a summary of the request will be sent to the provided e-mail address

Member Registry

Name

Surname

Group

Clinical Study Coordinator Traslational Radiotherapy

Mobile number

Used only for urgent communication event related

Phone number

Center information

Center Name

Address

Postal Code

Center Department

City

Region

Wrote 2 already MITO members who introduce you

Member N. 1

Member N. 2

Note