GNA-NES

Application for membership

You may use the following link to download the Application for Membership of the "Neurootological and Equilibriometric Society Reg." (NES). After filling the form, send it via fax or mail.

Download the application form:

application_form_2015.rtf.zip (9,463 bytes - .zip format)

To
Neurootological and Equilibriometric Society Reg. (NES)
Szigony utca 36.
H- 1083, Budapest, Hungary
Fax +36-1-3333316
E-mail: nes-gna@gmail.hu, szirmai.agnes@med.semmelweis-univ.hu

Herewith I apply for the membership in the Neurootological and Equilibriometric Society Reg., (NES), Szigony utca 36, H- 1083, Budapest, Hungary

 

Name:_____________________________________________________________

Surname:__________________________________________________________

Title / Institution:__________________________________________________

Street:__________________________________Nr________________________

ZipCode/City:______________________________________________________

Country___________________________________________________________

Tel.________________________________Fax____________________________

E–Mail___________________

 

In case of being accepted the NES is authorized by me, to annually draft the membership fee of USD 50.– from my bank account through an automatized drafting procedure by means of my credit card (give us the data of the card: (Visa or Mastercard, name on the card, number, valid expiry date, card verification code), or with bank transfer of the bank account number of the NES.

I know that I can end this drafting by written cancellation.

 

__________________________
Signature

__________________________
Date