membership application form - contraception-esc.com

(In case you don’t want to send the application form through Internet it is possible to print the Word or the pdf file and to send the membership form by post or fax.)

2008 ESC MEMBERSHIP FORM

The European Society of

Contraception

Personal information

Last name (family name):
First name:
Title:
Institute:
Department:
Street:
Postal code:
City:
Country:
Email address:

Payment section

AMOUNT DUE: 50 EURO (including the Journal of Contraception and Reproductive Health Care)

How

do you want to pay your membership fee?

* bank transfer in EURO to ESC account (IBAN) BE45 3101 2639

1389 ING bank, SWIFT code BBRUBEBB (bank address: ING bank, Marktplein 26, B-1740

Ternat, Belgium) with no costs for the beneficiary.

**if you prefer that we charge your credit

card (Eurocard/Mastercard/Visacard only) please fill out next details:

You can charge my

Card N^o:

CVC:

The Card Verification Code

(CVC) is printed on your MasterCard & Visa card in the

signature area of the back of the card. (it is the last 3

digits AFTER the credit card number in the signature area of

the card).

Exp.date:

Name of

Cardholder:

Automatically payment

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