Aortic Association membership application form

Aortic Association
Mrs. Eva Butler
Phone. +32 460 95 33 42
E-mail. eva.butler@aorticassociation.com
www.aorticassociation.org

Contact information *

Ms. Mrs. Mr. Dr.
Name *

First Name Last Name
Title *
Institution *
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code Country
Phone/Mobile

Area Code Phone Number
E-mail *
Payment option *
Annual Membership Rates *
Payment via Wire Transfer:

Name: Aortic Association

Bank: Raiffeisenbank Zürich

Bank address: Limmatquai 68 8001 Zürich

IBAN: CH52 8148 7000 0441 9450 2

BIC: 80808

SWIFT-Code: RAIFCH22

Reference: Aortic Association Membership fee
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Confirmation *

I confirm that, as far as I know, the information in this application is true and correct
Annual Membership Rates
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Physician 125.00 CHF

Fellow/Trainee/Nurse 50.00 CHF

Student 25.00 CHF

Industry Individual 175.00 CHF

Total 0.00 CHF
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