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MEMBERSHIP - YEAR 2012


Membership Fee Year 2012


New!! Please notice you can now register for 2 or 3 years with reduced fee

(only available for regular membership)



New!! Special fees for Emeritus


You can also print the PDF form for fax transmission to ECS secretary:
Prof. Jan B. Parys
Secretary-General ECS
Lab. Molecular and Cellular Signalling
K.U.Leuven
Campus Gasthuisberg O/N 1 - bus 802
B-3000 Leuven, BELGIUM
e-mail: jan.parys@med.kuleuven.be




Title:



First Name

required


Family name

required


E-mail address

required



ADDRESS DETAILS ONLY TO BE FILLED IN BY NEW MEMBERS OR IN CASE OF CHANGES


Department/Laboratory

required


Institution

required


Address

required


Postal Code

required


City

required


Country

required


Phone number

required


Fax number

required



Tick the appropriate box:


Regular Membership
Regular Membership 2012-2013-2014 (156 €)
 
Regular Membership 2012-2013 (110 €)
 
Regular Membership 2012 (60 €)


Emeritus Membership 2012
Emeritus membership 2012 (30 €)
    


Student Membership 2012
Student membership 2012 (30 €)
    
(For student membership, please send copy of ID student)


Payment by credit card:
Mastercard
 
Eurocard
 
Visa
Please complete the card information


Card number



Expiry date



Cardholder name



Payment (others):
Bank transfer to ECS account IBAN: BE95 0682 2443 2058 / BIC: GKCCBEBB (Bank Dexia, Blvd. Pacheco 44, 1000 Brussels, Belgium) (please join a copy)
    
In view of the very heavy fees imposed by banks, bank cheques can not be accepted. Sorry


Do you need a receipt?
Yes
 
No
  


If yes, please indicate e-mail address to which it has to be sent, if different from the above