ESPCOP

The European Society for Perioperative Care of the Obese Patient

Membership Application Form

 

Please fill in all required fields (in red) and e-mail the form as an attachment to the secretary Dr. Luc De Baerdemaeker: Luc.DeBaerdemaeker@UGent.be

Alternatively you can MAIL or FAX the form to:         ESPCOP  Secretary

Nathalie Anquez

Sint Jan Brugge-Oostende

Ruddershove 10

8000 Brugge, Belgium

Fax: 00 32 50 45 28 99

Nathalie.Anquez@azsintjan.be

 

 

Use the TAB-key to move forward to the next field – Shift-TAB to move backwards.

Membership number:
 (if applicable)

Family Name

                    

          

Title

First Name

Date of birth (dd/mm/yyyy)

     

          

          

E-mail address

                                            @                                                     

 

Professional address

Name of Hospital

          

Department

          

Street + number

          

Postal code

City

Country

          

          

          

Telephone (country code + area code + number)

Fax (country code + area code + number)

          

          

 

 

 

 

 

Alternative address (home)

Street + number

          

Postal code

City

Country

          

          

          

Telephone (country code + area code + number)

Fax (country code + area code + number)

          

          

Mobile number (country code + mobile phone number)

                                 

Preferred mailing address (Professional  / Alternative )

     

 Please check this box if you authorize the ESPCOP to list your name, hospital, city and country on the website

 Please check this box if you authorize the ESPCOP to list also your Email on the website.

I am also a member of:

 ESA               IFSO           

 ESICM           SOBA         

Other :           

Other :           

 

 

 

 

 

Type of ESPCOP membership

1 year

Full membership including IFSO membership

Full membership including IFSO membership with on-line access to Obesity Surgery (available from sept 2009)

Trainee membership including IFSO membership

(Trainees must enclose a letter from the Director of the training programme)

 

Trainee membership including IFSO membership with on-line access to Obesity Surgery (available from sept 2009)

 50 euro

 

 

 

130 euro 

 

 30 euro 

 

 

 

 

110 euro 

 

 

 

Payment information (we do not accept payment by cheque or cash!)

Please note that membership runs from January to December.

I hereby pay the amount of          euros for               membership .

Payment by bank transfer to account: ESPCOP anesthesie

 

 For transfer from Belgium:

 

ING Bank: 380-0184189-57

 

For international transfer:

 

BIC code:BBRUBEBB

 

IBAN code: BE09 3800 1841 8957

 

 

Please transfer the exact amount including any transfer costs if needed. If transfer from Europe in euro’s no extra costs are calculated using the IBAN and BICC code in automatic bank tranfers. Consult your bank for their policy:

 

 

 

Payment information (we do not accept payment by cheque or cash!)

Please note that membership runs from January to December.

I hereby pay the amount of          euros for               membership .

Payment by Visa/Eurocard/Mastercard

 

 Visa/Eurocard/Mastercard : N°                                    Expiry date             (mm/yy)

 Security number                (3 digits on the back of the credit card)

 

 Name of cardholder (if different from name of applicant) :            

 

The undersigned authorises ESPCOP to charge the above credit card with the above mentioned total amount.

Authorised signature**:

                                   ……………………………………………………………….

Please sign before faxing or posting the printed document to the ESPCOP. If you e-mail this form as an attachment to the ESPCOP, a signature is not necessary, but please mention the following text in the e-mail body:
“The sender of this e-mail authorises the ESPCOP to charge the credit card mentioned in the attachment with the total amount indicated on the form.”