APPLICATION FOR MEMBERSHIP

 

[please print out and write in block letters]

 

Name: .......................................................................................................................    m     f

                      (Last)                                  (First)                               (Middle Initial)

Academic Title/Degree/:............................................................................................................

Date of Birth:...........................................................................................................................

Department:.............................................................................................................................

Institution:...............................................................................................................................

Institution Address:.. ................................................................................................................

City/Country/Zip Code:.............................................................................................................

Phone:...................... ................................................................................................................

Fax:..........................................................................................................................................

e-mail:......................................................................................................................................

Date:................................ Applic. Signature:............................................................................           

 

Unless you indicate otherwise, the above information will be used for directory listing and for your mailing label. This application will only be considered if it is accompanied by the membership fee of DM 160,-(Euro 82), by means of credit card, Eurocheque (no personal cheques will be accepted) or a cheque drawn on a German bank made payable to:

 

                                     American Express                  Diners

                                                                                                      

                                      Master/Eurocard                     VISA

                                                                               

No.:..........................................................                                         Date of expiration:............................

                                                                                          

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

                                                                                         

The application should secure sponsorship by two members of the Society who should sign and date the application form.  

The application is then to be sent to:

         Prof. Jürgen Zulley, Treasurer ESRS                                Phone: +49 941 941 1500

         Bezirksklinikum                                                                 Fax:     +49 941 941 1505

         Universitätsstr. 84                                                              e-mail: juergen.zulley@bkr-regensburg.de

         D-93042 Regensburg, Germany                                        

        

Sponsor 1:      Sponsor's name  ....................................................................................................

                        Sponsor's statement: .............................................................................................

                        Sponsor’s signature:.............................................Date:.........................................

 

Sponsor 2:      Sponsor's name .....................................................................................................

                        Sponsor’s statement:..............................................................................................

                        Sponsor’s signature:...........................................  .Date:........................................

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