Form for Country Representatives (CRs)
Please indicate your name and surname in capital letters
NAME		
SURNAME		
Gender	•	Female
•	Male	
Title(s)	•	Professor
•	Associate Professor
•	Dr
•	Other, please indicate: …………………………………………..…….…….	
WORKING POSITION / AFFILIATION		
POSTAL ADDRESS		
ZIP CODE		
CITY		
COUNTRY		
Phone		
E-mail		
Keywords of your main scientific activities (3 to 4)	•	…………………..………..
•	…………………..………..
•	…………………..………..
•	…………………..………..	
Application should be sent to:
	Christelle Fablet, Secretary – christelle.fablet@anses.fr 
	Hermann Schobesberger, Treasurer – hermann.schobesberger@vetmeduni.ac.at