IEECPS Site Membership Application

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Site Data
Professional Background

Applicant's Authorization to Release Information

On behalf of the site, 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 the level of clinical training, experience, or professional competence with EECP/ECP therapy.

On behalf of the site, I agree that communications of any nature made to the Society regarding the site 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 this application for site membership.

On behalf of the site, I hereby certify that all information recorded on this application and any attached documents are accurate, which support the site's qualifications for membership in the International EECP Society. I hereby agree that the International EECP Society may verify any of the above data.

If elected, the site agrees to conform to the Bylaws of the Society and its Code of Ethics. Information available to it, which can be found at

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