24-26 November 2004, Oporto

Please complete and email this registration form to . You will receive confirmation of receipt within 3 working days. If you have any queries or problems you can email .

Section 1. PERSONAL DETAILS
Family name (surname): / Forename/s:
Title: Professor Dr Mr Mrs Ms Other:
Nationality:
Date of birth:
Affiliation (name of organisation) no more than 30 characters: it will appear on name badge:
Address:
Position / Main responsibilities:
Telephone number: / Fax number:
E-mail address:
Section 2. EA-OHP Membership (please tick as appropriate)
Attendance at the conference bestows free membership of the Academy for the following year. Delegates at Oporto 2004 will pay no membership fee for 2005. Renewal or new membership applied for at any other time of year will be subject to the appropriate fee.
I am a member of the Academy but did not attend the Berlin 2003 conference and I would like to take advantage of the membership offer for the next year and renew my membership My membership number is ______
I am a member of the Academy and did attend the Berlin 2003 conference and I would like to take advantage of the membership offer for the next year and renew my membership
Please provide a list of publications from the last twelve months, if you are renewing your membership
I am not currently a member of the Academy but would like to take advantage of the membership offer for the next year
Please also complete Section 5 if you have ticked this box
Section 3. CONFERENCE REGISTRATION (please tick as appropriate)
Form received on or before 1st October 2004 / Form received after 1st October 2004 / On-site registration
EA-OHP Member (2004) / €404* or £270 / €456 or £305 / €516 or £345
Non-member / €464 or £310 / €516 or £345 / €569 or £380
Employed in a WHO-recognised developing country / €344 or £230 / €397 or £265 / €449 or £300
Student (EA-OHP member or non-member) / €224 or £150 / €224 or £150 / €299 or £200
Names of travelling companions: ______
Section 4. ADDITIONAL INFORMATION for conference delegates
Do you have any special dietary requirements (e.g. vegetarian, vegan, food allergies, etc.)? Please specify:
No Yes ______
Do you have a disability? If ‘yes’, please describe the condition and the appropriate arrangements that need to be made.
No Yes ______
What is your main focus of activity in relation to OHP (please tick as appropriate):
Research Education Practice Other:______
Where did you hear about the EA-OHP?
Section 5. ADDITIONAL INFORMATION for new Academy members
Educational qualifications (e.g. BSc, PhD) / Title (e.g. Applied Psychology) / Awarding Institution / Year
Membership of other Institutions or chartered bodies (including level of membership):
Experience in or related to Occupational Health Psychology please briefly describe your active involvement in OHP
Involvement in research in OHP (including funded projects) over the last 3-5 years:
Involvement in education in OHP over the last 3-5 years:
Involvement in professional practice relevant to OHP over the last 3-5 years:
Please list three most recent publications relevant to OHP (can be attached separately):
Section 6. APPLICATION/REGISTRATION FEE PAYMENT
I enclose a cheque for £______payable to the EA-OHP OR
Please charge my card for £______conference registration fees
Credit Card Type: Visa MasterCard American Express Switch
Card number:
Expiry Date: / Switch card issue number:
Cardholder’s name (as it appears on the card) and address:
I would like my membership to be debited to this credit account annually (direct debit)

* All conversions made 1st March 2004: £1=€1.50 Click here for currency conversion

All information will be kept and processed in accordance with the Data Protection Act 1998

Postal address:

European Academy of Occupational Health Psychology

c/o Institute of Work, Health & Organisations (I-WHO), University of Nottingham, Science and Technology Park, University Boulevard, Nottingham NG7 2RQ, UK

website: www.ea-ohp.org fax number: +44 (0)115 846 6625 email: , information@ ea-ohp.org

The European Academy of Occupational Health Psychology

Europe’s leading body for individuals and institutions with an active involvement in the research, professional practice, and education of occupational health psychology.

European Academy of Occupational Health Psychology