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Federation Assembly membership form

Name of Neurointervention Society: *

Number of members:

Year society constituted:

Country of registration:

WFITN assembly delegates

Delegate 1 Name *

Delegate 1 email *

Delegate 1 phone number *

Delegate 2 Name

Delegate 2 email

Delegate 2 phone number

Alternate Name

Alternate email

Alternate phone number

Society Contact details

Administrator Name *

Administrator email *

Administrator phone number *

Name of person completing form *

Position in Society *

Signature / Date *

Society constitution file *

Files must be less than 2 MB.
Allowed file types: pdf doc docx.

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