WHY JOIN ESPEN



The European Society for Clinical

Nutrition and Metabolism

BAPEN BLOCK MEMBERSHIP SUBSCRIPTION FORM 2018

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|First Name: | |Title: | |

|Address: | |

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|ESPEN Membership No: | |Date of Birth: | |

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|Username: | |

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Are you (Please select one of the following)

| |Physician/Surgeon |

(Please tick the appropriate box)

| |Membership fee including subscription to “Clinical Nutrition is £81.00 payable to BAPEN |

| |Junior Membership fee including subscription to “Clinical Nutrition is £36.00 payable to BAPEN |

| |Senior Membership fee including subscription to “Clinical Nutrition is £36.00 payable to BAPEN |

If applying for Junior (under the age of 32 years) or Senior (over the age of 65 years) Membership please submit a copy of a document that confirms your date of birth.

Payment (Please tick appropriate box)

| |Credit Card | |Cheque enclosed payable to BAPEN |

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|Card Number: | | | | |

|Card Valid from: | |Card expires: | |

|CSC (last 3 digits on back of card | |Issue Number | |

|or 4 on front for Amex) | |(if applicable) | |

Important note: Please add the corresponding “Card Validation Code” (CSC) - three or four last digits printed at the back of your card

|Date: | |Signature: | |

IMPORTANT

PLEASE RETURN BY WEDNESDAY 31st JANUARY 2018 AT THE VERY LATEST TO ENSURE MEMBERSHIP

Please return the completed form to: BAPEN Office, Seven Elms, Dark Lane, Astwood Bank, Redditch, B96 6HB

Email: bapen@.uk

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