ESACP Membership Renewal 1999

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    • For ESACP members who want to regulate their dues for 1999. Please print this form from the Internet and submit it by mail or telefax.
    ESACP Membership dues for 1999 will be 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

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

    ___ 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 PD Günter Haroske
    Institut für Pathologie
    Medizinische Akademie
    Fetscherstr.74
    D-01307 Dresden
    Germany
    Tel: +49/351/458-3005, Fax: +49/351/458-4358
    E-mail: haroske@rcs1.urz.tu-dresden.de

    ESACP Bank account: 05 503 255 01, Dresdener Bank, Dresden, BLZ: 850 800 00

    Last update: Mar.20, 1999

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