Membership Application Form*
Name
Date of birth
Professional Discipline and Appointment
Employment Address
Home Address
Address for Correspondence
Home
Employment
Contact Telephone Number
Fax
Email
(The majority of ILAE correpondence is now via email so please be sure to provide an email address)
Professional interests in epilepsy
*
A completed Standing Order form is also required to be sent at the same time as the Membership Application.
Please click here for the Standing Order Form and instructions >>>>>
