CONffIDENCE Stakeholders Registration Form

Your contact information will only be used for dissemination of the CONffIDENCE project, we will not make this information available to others outside the project.

With your permission, we would however like to list your institution (not your name or contact information) on our website. If you do not wish to have your organization listed as a stakeholder on our site, please indicate this below.

Stakeholder information:

* required information

Professional data

First name: ex: 'Paul'

Last name: ex: 'de Jong'

Title:

Function:

* Organisation:

* Type of organisation:

Website: ex: 'http://www.MyWebsite.com'

Address:

City: ex: 'PARIS'

Postcode:

State/Country:

Telephone: ex: '0900-858548'

* e-Mail:

Tick off your main areas of interest:

Environmental pollutants
Pesticides
Natural toxins
Heavy metals
Veterinary drugs

I do NOT wish my organization name to be listed as a stakeholder on the CONffIDENCE website

Enter the code*