Form ERT OLD – Sociedade Portuguesa de Farmacologia

Full name

Date of birth

VAT Number

Gender

Male Female

Home Address

Work Address

Phone Numer

E-mail

Employer

Job Position

How long have you worked in the field of toxicology?

Please send all correspondence to:

Home address Work address E-mail address

I am a member of:

SPF AP Tox None

Academic Education completed:*

Degree Level (i.e. Master)

Field of Study

University Name

Date of completion

Country:

Degree Level (i.e. Master)

Field of Study

University Name

Date of completion

Country:

Degree Level (i.e. Master)

Field of Study

University Name

Date of completion

Country:

Copy of all certificates MUST be sent with the application. Only certificates with text in Portuguese and English will be accepted. Please ensure an official translation if required.

I hereby apply for registration as a registered toxicologist on the basis of:

Route 1: Attendance of appropriate course Route 2: Practical experience and on the job training Re-registration

Recommendation Letters

Please list the names and other relevant information regarding the two expert reviewers that support your application. (please note that the expert reviewer’s opinion letter must be submitted with the application).

Expert Reviewer Name

Relevant Information

Expert Reviewer Name

Relevant Information

Route 1 Applications

Applicants are to complete all parts of part A and at least two from part B. Copy of all certificates MUST be sent with the application. Only certificates with text in Portuguese and English will be accepted. Please ensure an official translation if required.

PART A: COMPULSORY/MANDATORY TOPICS

Topic/Course Name*