Please
fill out the form, print it, check whether the information
provided is correct and complete, add your signature
and return it by ordinary mail to the treasurer of ESERA:
Dr.ir. Koos Kortland, FIsme University of Utrecht, PO
Box 80.000, 3508 TA Utrecht, the Netherlands.
Please
note that for security reasons the completed form cannot
be submitted electronically. However, if the completed
form does not contain credit card information, it can
be sent by E-mail as a Word or PDF attachment to the
treasurer of ESERA:
This application form concerns:
New
membership
Membership
renewal
Personal
information
Family
name:
First
Name:
Title:
Institution:
Address
of Institution:
Telephone:
country code
area code
number
Fax:
country code
area code
number
E-mail:
Research
Interest:
Methods
of payment
credit
card
60 Euro for two years
bank
transfer
60
Euro for two years
PhD
student (free of charge for the duration of the
PhD study).
I expect to finish my PhD study in year
retired
Payment
by bank transfer
Bank transfers to ING Bank 1027413 of ESERA, c/o J.
Kortland, Postbus 80000, 3508 TA Utrecht, the Netherlands
IBAN: NL 61 INGB 0001 0274 13
BIC: INGB NL 2A
Please note that your bank may add extra charges if
you choose to pay by bank transfer.
Payment
by money order
Please note that payment by cheque or money order involves
relatively high cashing costs for ESERA. Therefore,
when paying in this way a surcharge of 10 Euro must
be added to the membership fee. So: 70 Euro for two
years.
Payment
by credit card
If paying by credit card, please supply the following
information as stated on the card:
Card
type:
VISA
MASTERCARD
Card
Holder:
Card
Number:
CVC
security code:
(the last three figures at the back of the card
next to the signature)
