ESACP Membership Renewal 1997

For present ESACP members who want to regulate their dues for 1997 or for ancient ESACP members who want to reattach to ESACP in 1997. Please print this form from the Internet and submit it by mail or telefax.

ESACP Membership dues for 1997 are 185 DM including subscription to the Analytical Cellular Pathology Journal. The address and telecommunication information will be incorporated into the annual ESACP membership directory.

Family Name (to identify payment) : ...............................................................................................

First Name: .......................................................................................................................................

___ Bank Transfer in DM (please join transcript)

___ Euro-Cheque (issued in DM and joined)

___ Master/EuroCard ___ Visa ___ American Express

Card Nr: ___ ___ ___ ___ ||| ___ ___ ___ ___ ||| ___ ___ ___ ___ ||| ___ ___ ___ ___

Expiry Date: ............................................. Signature: ......................................................................

Address (if changed)

Institution or affiliation: ...................................................................................................................

Street: ...............................................................................................................................................

Street number: ..................................................................................................................................

P.O. Box: ..........................................................................................................................................

City: ..................................................................................................................................................

ZIP Code: .........................................................................................................................................

State: ................................................................................................................................................

Country: ............................................................................................................................................

Telecommunication (if changed)

Telephone (country/area/number/extension): ...................................................................................

Fax number: ......................................................................................................................................

E-mail: ..............................................................................................................................................

Internet homepage: ...........................................................................................................................

IMPORTANT NOTE:

Please return this form together with your bank transfer transcript, Euro-Cheque or credit card information to the:

ESACP membership office:
c/o Prof.Dr.G.K.Valet
Max-Planck-Institut für Biochemie
Am Klopferspitz 18a
D-82152 Martinsried
Germany
Tel: +49/89/8578-2518, -2525, Fax: +49/89/8578-2563
E-mail: valet@biochem.mpg.de

ESACP Bank account: 571 548 701, Deutsche Bank , München-Großhadern, BLZ: 700 700 10

Last update: Apr.21, 1997