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REGISTRATION FORM
Name: …………………………………………………………… Surname: ………………………………………………………..
Profession: • Psychoanalyst • Psychoanalytic Candidate • Psychologist • Psychiatrist • Psychological Counselor • Social Service Specialist • Psychiatric Nurse • Student/Assistant
Degree of education and/or academic title: …………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………….
Place of occupation and/or institution of training…………………………………………………………….. ……………………………………………………………………………………………………………………………………………….
Address: ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………….
Postcode: ………………………………………. City: …………………………………………………………………………..
Telephone: ………………………………………………………. e-mail: ……………………………….@…………………………