IEECPS Membership Application

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Personal Data

Professional Background

Applicant’s Authorization to Release Information

I hereby consent to the release by any hospital, educational institution, governmental agency, physician, professional society, or other person possessing or requiring the same, whether or not listed above, of any and all information in any way pertaining to my personal character, training, experience, or professional competence.

I agree that communications of any nature made to the Society regarding my fitness for membership may be made in confidence and shall not be made available to me under any circumstances. I hereby release from any liability any and all individuals and organizations or their authorized representatives who provide this information in good faith and without malice subject to this consent. I hereby release from all liability the International EECP Society and any and all individuals for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications.

I hereby certify that all information recorded on this application and any attached documents is accurate and supports my qualifications for membership in the International EECP Society for which I now apply. I hereby agree that the International EECP Society may verify any of the above data.

If elected, I agree to conform to the Bylaws of the Society and its Code of Ethics. Information available to me can be found at

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