ESPD membership registration 2010
I intend to renew/start my membership of the ESPD and ,accordingly, will pay the fee of
40 Euros (subscription to "Pediatric Dermatology" NOT included)
100 Euros (subscription to "Pediatric Dermatology" INCLUDED)
Title, Name & First Name:
Institution:
Address:
Post code:
City:
Country:
E-mail:
Phone:
Fax:
Agrees that personal data appear on the website in the list of members page?
I agree.
I do not agree that these data are put on the website.
Payments can be made by bank transfer or credit cards:
Bank transfer to the order of ESPD on the following account:
Fortis Bank
Belgium
Account Number 001-4130724-55
Swift code: GEBABEBB
IBAN code: BE31 0014 1307 2455
Debit my VISA or EUROCARD:
Enter the code shown:
