49 ERA-EDTA CONGRESS - ERA-EDTA Congress 2012
49 ERA-EDTA CONGRESS - ERA-EDTA Congress 2012
49 ERA-EDTA CONGRESS - ERA-EDTA Congress 2012
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Ma i n an n o u n c e M e n t<br />
<strong>49</strong> th <strong>ERA</strong>-<strong>EDTA</strong> <strong>CONGRESS</strong><br />
MAY 24-27, <strong>2012</strong><br />
PARIS, France<br />
<strong>ERA</strong>-<strong>EDTA</strong> Membership Payment Form <strong>2012</strong><br />
PAYMENT BY CREDIT CARD – VISA / EUROCARD-MASTERCARD<br />
(Please complete the form in capital letters or type and send to the <strong>ERA</strong>-<strong>EDTA</strong> Membership Office)<br />
Last name:_____________________________ First name:________________________ <strong>ERA</strong>-<strong>EDTA</strong> n°______ (office use only)<br />
Credit Card: o Visa o Eurocard/Mastercard - (in both cases write all 16 numbers below)<br />
Card number: - - - / - - - / - - - / - - - - Expiry Date /<br />
o EUR 125.00 - Full Fee o EUR 50.00 - Reduced Fee o Other: .......................................<br />
o EUR 90.00 - Online fee o EUR 50.00 - Junior Fee<br />
o EUR 85.00 - Spec. Full Disc. Fee o EUR 35.00 - Spec. Online Disc. Fee<br />
For more details regarding the fees see the next page<br />
IMPORTANT: if no box is ticked, then the full fee will be cashed!<br />
If the card owner is different from the <strong>ERA</strong>-<strong>EDTA</strong> Member, please write his/her full name:_________________________________<br />
Date______________________ Signature_____________________________________________<br />
A receipt is automatically sent with the membership card.<br />
SEND THIS FORM TO:<br />
<strong>ERA</strong>-<strong>EDTA</strong> Membership Office<br />
c/o Mrs. Monica Fontana Faughnan – Office Manager<br />
Via Aldo Moro, 18 - 35030 Bastia di Rovolon (PD) – ITALY<br />
Phone: +39-0<strong>49</strong>-9913028 - Fax: +39-0<strong>49</strong>-9910957<br />
e-mail: membership@era-edta.org<br />
PAYMENT BY BANK TRANSFER<br />
(Please include the information requested below when filling in the bank transfer forms.<br />
Send NET AMOUNT ONLY, NO CHARGES FOR US)<br />
Last name:_______________________ First name:___________________________ <strong>ERA</strong>-<strong>EDTA</strong> n°___ (office use only)<br />
Amount:_____________________________ Year paid for: <strong>2012</strong><br />
Account holder: European Renal Association - European Dialysis and Transplant Association (<strong>ERA</strong>-<strong>EDTA</strong>)<br />
Account number: 236-473242.61M<br />
Bank: UBS SA; Casella Postale; CH-6830 Chiasso; Switzerland.<br />
IBAN: CH69 0023 6236 4732 4261 M<br />
BIC/SWIFT: UBSWCHZH80A<br />
o EUR 125.00 - Full Fee o EUR 50.00 - Reduced Fee o Other: .......................................<br />
o EUR 90.00 - Online Fee o EUR 50.00 - Junior Fee<br />
o EUR 85.00 - Spec. Full Disc. Fee o EUR 35.00 - Spec. Online Disc. Fee<br />
For more details regarding the fees see the next page<br />
A receipt is automatically sent with the membership card.<br />
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