MLTD : THE MEDITERRANEAN LEAGUE AGAINS THROMBOEMBOLIC DISEASES : Membership Form

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11/03/2010

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New Members ONLY

Membership Form for printing

STEP 1/5

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ACCOUNT DATA

* Username

* Password

* Repeat Password

* e-mail

If you have already registered, please log in to your Private Area using your username and password and click on Membership - Renewal Fee 2010.
Please choose a username and a password. You will need them in your future visits to access the Private Area.

Title	* Name	Middle Name

	* Last Name

WORK ADDRESS

* Institution/Organization

Web Site

Department

Address

Phone #

Postal Code		City		State/Province

Fax #

Country

ACADEMIC DEGREE
M.D.
Ph.D.
D.Sc.
Other

Current Professional Position

FIELD OF WORK
Academic
Commercial
Non-Profit
Hospital/Clinic Facility
Private Clinical Practice
Other

PERSONAL DATA

Personal Address

Personal Phone #

Postal Code		City		State/Province

Other Phone #

Country

PAYMENT TERMS & CONDITIONS: Regular Member Annual fee for 2010: 35,00 €

BANK TRANSFER (Bank commission will not be accepted)

Please fax a copy of the Bank transfer's receipt
to the following number: +34 963 942 558
We cannot renew you membership until we receive this proof of payment.

BANK INFO:
Banco Santander Central Hispano
Gran Vía 4º 1ª
48001 Bilbao (Spain)

Account number: 0049 1800 13 2710387658
IBAN No. ES63 0049 1800 13 2710387658
SWIFT Code: BSCHESMM

CREDIT CARD (No extra fees will be charged)

* Holder's name

* Credit Card No.

* Exp. Date

* Safety Code No.

Invoice Request

* Name		* I.D. Tax No.

* Address

DIRECT BILLING (Domiciliaci�n Bancaria - Spanish residents only)

Please fill in all the fields for the direct billing of your membership fee. Once the form has been filled in, please print it out and sent it by fax (+34 963 942 558) or by ordinary mail to the Technical Secretariat: Universidad, 4, 46003 Valencia.

* Account Holder's name

* Account Number

* BANK NAME		* Bank Adress

* Postal Code/ Zip Code		* City		* Province/ Estate		* Country

* I accept terms and conditions

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* Red fields are compulsory

PRIVATE AREA


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Last Update 21/1/2009

MLTD Technical Secretariat: tel.(+34) 963 524 889 - fax (+34) 963 942 558 - mltd@geyseco.es