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ISMNI Secure Registration
Form
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I would like to become a member of ISMNI and I agree with the Society's Bylaws. |
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Membership renewal |
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First Name(s) |
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Initials |
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Last Name |
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Degree(s) |
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Specialty |
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Department |
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Institute |
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Mailing Address |
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City |
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State |
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Zip Code |
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Country |
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Phone(s) |
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Fax(s) |
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E-mail |
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Please tick the appropriate box |
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Institutional rate ( 110
€)
Personal rate ( 60 €
)
Resident/Student rate (
45 €) |
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Please indicate method of Payment |
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By bank tranfer to:
Berliner Sparkasse.
Alexanderplatz 2, 10178 Berlin
Acc. No. 660 404 5038
BLZ: 100 500 00
Acc Holder's name: medical event solutions GmbH, Mrs Yvonne Beetz,
IBAN: DE54 1005 0000 6604 0450 38
SWIFT/(BIC) Code: BELADEBEXXX
Identification Number: DE 247500978.
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By VISA credit card. |
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By MASTERCARD credit card. |
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By American Express (AMEX) credit card. |
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Card Holder's Name
Card Number
Card security code
Printed on the back side of your credit card
Card Expiry date
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