EUSOBI 2010 Membership Fee Application/Payment:

EUSOBI Membership fee is currently set at € 40,00 per year
Personal Information:


Title: *
Gender: * female    male
First Name: *
Last Name: *
Date of birth: *
DD MM YYYY
Profession: *
Specification:
Hospital:
Department:
Street: *
Zip/ City: *
/ 
Country: *
Phone: *
Fax:
E-mail: *
re-type E-mail: *
* required field


Payment method:
Banktransfer:
"Die ERSTE Bank"
Bank code:   20111
Account number:   051-51058 (EUSOBI)
IBAN:   AT972011100005151058
BIC: GIBAATWW

Please indicate your full name and purpose "EUSOBI 2010 Membership" on bank transfer
documents.
Please note that you are responsible for any bank charges that may occour.
Credit card:
Credit card type:
Name of Cardholder:
Credit card number:
Expiry date:  MM    YYYY



Finish Application:


 I herewith confirm the accuracy of the information provided.*