Questionnaire to become
Corresponding Member of Groupe Mercurius

Groupe MERCURIUS, 524 rue Robert Schuman, 30000 NIMES, France

   Your datas are the same than the 2010-2011 directory   : q

NAME : ……………………………………………..

SURNAME :  …………………………………

ADDRESS : street  ……………………………………………..

postal code  …………….   TOWN      ……………………………………………..

TEL. (international call)  ……………………………………………..

TEL. (local call)    ……………………………………………..

FAX (international call)    ……………………………………………..

FAX (local call)    ……………………………………………..

Mobile     ……………………………………………..

E-mail        ……………………………………………..

PROFESSION :                                                     PROFESSIONNAL Mark

general PRACTIONER

DENTIST

VETERINARIAN

spécialist PRACTITIONER  :          q  ..............................

NATUROPATH

HEILPRAKTIKER

MIDWIFE

OTHER : q  ............................

Homeopathy practice :

classical homeopathy : frequently q     occasionally q

french homeopathy : frequently q     occasionally q

Homeopathic formation : schools/methods/groups

...............................................................................................................

...............................................................................................................

Other medicinal practices : ...........................................................

Web directory (e-directory)

I wish only my name, address (no email) and homeopathic formation be in the e-directory : q

otherwise :

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