Please Fill in All Required Fields (In Red) and Fax the Form to ESPCOP Secretary Nathalie Anquez

ESPCOP The European Society for Perioperative Care of the Obese Patient

Membership Application Form Please fill in all required fields (in red) and fax the form to ESPCOP Secretary Nathalie Anquez Sint Jan Brugge-Oostende Ruddershove 10 Fax: 00 32 50 45 28 99 8000 Brugge, Belgium [email protected] [email protected]

Membership number: Family Name

Title First Name Date of birth (dd/mm/yyyy)

E-mail address @

Professional address Name of Hospital

Department

Street + number

Postal code City Country

Telephone (country code + area code + number) Fax (country code + area code + number)

Alternative address (home) Street + number

Postal code City Country

Telephone (country code + area code + number) Fax (country code + area code + number)

Mobile number (country code + mobile phone number)

Preferred mailing address (Professional / Alternative )

Please check this box if you authorize the ESPCOP to list your name, hospital, city and country on the website Please check this box if you authorize the ESPCOP to list also your Email on the website. I am also a member of:

ESA IFSO Other : ESICM SOBA Other : Type of ESPCOP membership 1 year

Full membership including IFSO membership from sept 2009 50 euro

Full membership including IFSO membership with on-line access to Obesity Surgery (available from sept 2009) 110 euro

Trainee membership including IFSO membership from sept 2009 30 euro (Trainees must enclose a letter from the Director of the training programme)

Trainee membership including IFSO membership with on-line access to Obesity Surgery (available from sept 2009) 90 euro

Payment information (Bank transfer) Please note that membership runs from January to December. I hereby pay the amount of euros for membership . Payment by bank transfer to account: ESPCOP anesthesie

For transfer from Belgium: For international transfer: ING Bank: 380-0184189-57 BIC code:BBRUBEBB IBAN code: BE09 3800 1841 8957 Please transfer the exact amount including any transfer costs if needed.

Payment information (Visa/Eurocard/Mastercard) Please note that membership runs from January to December. I hereby pay the amount of euros for membership . Payment by Visa/Eurocard/Mastercard

Visa/Eurocard/Mastercard : N° Expiry date (mm/yy) Security number (3 digits on the back of the credit card)

Name of cardholder (if different from name of applicant) :

The undersigned authorises ESPCOP to charge the above credit card with the above mentioned total amount. Authorised signature**: ………………………………………………………………. Please sign before faxing or mailing the printed document to the ESPCOP.