ISDS Subscription Form - 2010 and 2011
| Personal Information |
| Name |
| Address (professional) |
Phone Number
|
FAX Number
|
| Email address |
| Credit Card Information |
| Name (as it appears on card) |
| Type of Credit Card (VISA or Mastercard; American Express not accepted, sorry!) |
| Credit Card Number |
| Expiry date (mm/yy) |
| Please
check: |
| ___ Regular fee (150 CHF) |
| ___ Reduced fee (50 CHF) (Student/ Postdoc/ Resident/ Counsellor/ Emeritus) |
| The fee for ISDS membership until December 2011is 150 Swiss Francs (CHF) (approx. 110 Euro or 140 US $ as per April 2010) |
| As per a Business Meeting 2003 decision, a reduced fee of 50 Swiss Francs (CHF) applies to all Students, Predoctoral and Postdoctoral Trainees and Residents (prior to Board/Specialty Certification), to Genetic Counselors, and to Emeriti/Retirees (please specify your condition when applying) |
| PLEASE USE A CREDIT
CARD - do not send cheques or bank payment instructions,
and any form of payment in USD or other currencies! Expenses
for cashing those are much too high, and procedures too
complicated! THANK YOU!
|
If payment by credit card is not possible, and you wish to pay by money transfer or by cheque, 40 CHF must be added to the subscription fee because of additional bank costs: -make cheques payable to the International Skeletal Dysplasia Society -data for money transfer are: Bank: UBS
Union Bank of Switzerland, Zürich-Römerhof, Switzerland - In both cases, PLEASE
ADD 40 CHF to the subscription fee to cover for the additional costs! |
Please print out this form, fill it in and mail or fax it to:
PD Dr Luisa Bonafé, MD, PhD
Division of Molecular Pediatrics
Centre Hospitalier Universitaire Vaudois
Clinique Infantile 02-35 Av. P. Decker 2
1011 Lausanne, Switzerland
Phone: +41-21-3143483
Fax: +41-21-3143546
Email: luisa.bonafe (at) chuv.ch
(Subscription to the Skeldys Email List is done automatically by the Secretary and List Administrator upon completion of payment)