WHY JOIN ESPEN
The European Society for Clinical
Nutrition and Metabolism
BAPEN BLOCK MEMBERSHIP SUBSCRIPTION FORM 2018
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|ESPEN Membership No: | |Date of Birth: | |
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|Username: | |
|(If a former member) | |
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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