DECLARATION of the ACCESION 
to the POLISH SYNCHROTRON RADIATION SOCIETY 

Family name and first name:.........................................................................................................……… 

Title:…………………………..Date and place of birth:… ......................................................…………….

Home address:….....................................................................................................................................

Affiliation(s):...............................................................................................................................................

Professional address:………............................................................................…………………………….

.............................................................................................................................................................….

Phone:...................................... Fax:........................................ E-mail: .....................................................

PSRS membership: associate member  / full member  *

I hereby declare that I have read the PSRS Information Clause regarding the processing of personal data.
I hereby declare that the personal data provided in this membership declaration have been submitted voluntarily and are true.

Date ………………………………                   Signature…………………………………………………..