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SSL Certificate Authority



Authorised to Accept Credit Cards

ETCC Payment Form 1

EUROPEAN TRANSPLANT COORDINATOR CERTIFICATION - PAYMENT FORM

Please fill in:

Bussines Address :
(Print your name as you wish it to appear on your certificate of competency)
Last Name:
 First Name:  
Bussines Address:
 Country:  
Postal Code:
City:  
Phone Number: Fax:  
Email:      

Personal Address :
Personal Address:
 Country:  
Postal Code:
City:  
Phone Number: Fax:  
Email:      

Payment Information :
 I prefer to regulate the membership fee as follows:

Amount to Become an ETCO Member:

 EUR €

By charging my VISA / MASTER / EURO Card

Card number:
Name Card Holder:
Exp. date: / (mm/yy)
 

 
By bank-to-bank transfer
(please note that such transfer requires a considerable amount of bank charges)

Fortis Bank, Kantoor St.Jacob, BE-3000 Leuven, Belgium
Please mention "Certification & your name " as reason of payment !!
For payments made in Belgium:
Account nr.: 230-0075242-87		 For payments out of Belgium:
IBAN-code: BE67 2300 0752 4287
BIC-code or SWIFT-code: GEBABEBB
Fortis Bank

Crossed cheque, certified by your bank:

Pleased send to:

ETCO Executive Office
Mrs Jane Lewis
Carrer Joan Maragall, 12
08360 - Canet de Mar
Barcelona - SPAIN
Remember that " All bank charges to the account of the applicant "


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National Key Members Annual Meeting of ETCO Certification Future Congress Etco Board
Recommended Bibliography Donation Bibliography Transplantation Guidelines Future Events Congress in Prague 2007
Transplant Organizations Transplant Centers Europe Journals Transplantation Donation Forums Organ Procuremenet
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