Name of legal representative:
Function:
Department:
Faculty:
Address:
Phone:
Fax:
e-mail:
	The above legal representative endorses the participation of this institution in thematic network MED-NET (Medical Education and Didactics NETwork) in the SOCRATES ERASMUS programme of the European Union. The registration number of the thematic Network is 25820-CP-1-96-1-NL-ERASMUS-ETN.
On behalf of our institution the following person was appointed as the direct contact person for MED-NET:
MED-NET Contact Person:
Function:
Department:
Faculty:
Address:
City & Postcode:
Country:
Phone:
Fax:
e-mail:
Signature:	..............................................
Date:	..............................................

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If you prefer to send this form by ordinary mail, please print out the completed form and mail it the address below. (*Don't forget to add your signature if sending by mail)

MED-NET
Ir. Jan de Koning
101 CSC, Faculty of Medical Science
University of Nijmegen
P.O. Box 9101
6500 HB Nijmegen
The Netherlands