Membership Application Form for the International Association for Hydrogen Safety – IA HySafe

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Please print this page (or the pdf file), fill it out and send it per fax to the association secretary:

Prof. Andrzej Teodorczyk
Warsaw University of Technology
Instytut Techniki Cieplnej (ITC)
(Institut of Heat Engineering)
Nowowiesjska 21/25
00-665 Warszawa
Polland
Tel. +48 (22) 234 5226
Fax +48 (22) 234 0565
Email info@hysafe.net

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Organization details:

  1. Name of Organization ……………………………………………………………………………
  2. Department (if applicable) ………………………………………………………………………
  3. Type of Organization (Industry, research Centers or Universities), others ……..
    ………………………………………………………………………………………………………….
  4. Country…………………………………………………………………………………………….
  5. Full Office address (Street, Nr, Post Code, City, Country)……………………………..
    ………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………….
  6. Office Phone…………………………………………………………………………………………
  7. Office Fax……………………………………………………………………………………………
  8. Website………………………………………………………………………………………………
  9. Name of Contact Person…………………………………………………………………………..
  10. Phone…………………………………………………………………………………………………
  11. Email Address………………………………………………………………………………………..

Applicant’s  details (to be completed only if private person applies for membership):

  1. Name, Surname …………………………………………………………………………………….
  2. Date and place of birth ……………………………………………………………………………
  3. Gender…………………………………………………………………………………………………
  4. Nationality……………………………………………………………………………………………
  5. Country of Residence……………………………………………………………………………….
  6. Address/City/Town/Postcode:………………………………………………………………..
    …………………………………………………………………………………………………………..
  7. Mobile phone:………………………………………………………………………………………..
  8. Contact email:……………………………………………………………………………………….
  9. Scientific degree…………………………………………………………………………………….
  10. Education, occupation, position ………………………………………………………………
    ……………………………………………………………………………………………………………
  11. Scientific area………………………………………………………………………………………..
  12. Interest in Hydrogen safety activity………………………………………………………………

Membership is open to legal entities and private persons interested in hydrogen safety.

Yearly Membership fees:

For large and medium industry and research institution, associations:
Full Membership:  3000 € . Associated membership:  1500 €

For small industry and research institution, Universities:
Full Membership: 1500€. Associated membership: 750 €

Private person (as associated member only):  100 €

I, herby, accept the conditions for membership as laid down in the statutes and apply the admission to IA HySafe as full / associated / private member

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Signature of applicant

The association reserves the right to refuse membership applications. The applicants will be informed accordingly.