ESPNIC Membership Services

c/o Kenes International Organizers of Congresses S.A

7, rue François-Versonnex,

C.P. 6053,

1211 Geneva 6, Switzerland

Tel: +41 22 906 91 78; Fax: +41 22 73226 07

Email:

ESPNICOFFLINE APPLICATION FORM

Please complete this form clearly and accurately to avoid any errors with your ESPNIC membership.

Title (please check one box only):Prof.Dr.Mr.Mrs.Ms.

Last Name First Name

Email Address Country

House number Address Line 1

Address Line 2 State

Zip Code Phone number (Country Code/City/phone number)

Please select the section you wish to be a member to support its various scientific activities:

Please note that you can be a member of any section, however, you can only vote in one section. Please highlight in which section you wish to vote.

Respiratory Failure
Ethics
Paediatric and Neonatal Intensive Care Nursing
Infection, systemic inflammation and sepsis
Neuro critical care
Nursing Science Group
Resuscitation & emergency medicine
Metabolism, endocrinology and nutrition
Pharmacology
Health services research, administration, education, information technology/Long term outcome
Renal CRRT
Cardiovascular Dynamics
Cardiac ICU and Mechanical circulatory support
Transport

ESPNICMEMBERSHIP DUES:

The following membership dues are valid for one calendar year (January to December)

2016 Only / 2016-17
Nurse member Europe / EUR 45 / EUR 85
Nurse member Non-Europe / EUR 50 / EUR 95
Nurse member Europe from developing country* / EUR 30 / EUR 55
Nurse member Non-Europe from developing country* / EUR 35 / EUR 65
Nurse Trainee / early career** / EUR 30 / EUR 55
Allied health Professional / EUR 50 / EUR 95

*For the list of countries please check ESPNIC website:

**Nurse Trainee/Early career: Nurses in training in the field of Paediatric intensive care

JOURNAL SUBSCRIPTION:

2016 Only / 2016-17
Intensive Care Medicine / EUR 100 / EUR 200
Nursing in Critical Care / EUR 42 / EUR 84
Infant Journal (neonatal) / EUR 45 / EUR 90

PAYMENT:

Please select a payment option below and fill the corresponding information:

Option 1:Credit CardVisaMastercardAmerican Express

Name as it appears on the card

Card NumberExpiry date (mm/yy)CVV

Option 2: Bank transfer – please ensure that “ESPNIC Membership fee” and the name of the member are clearly marked on the transfer. If payment is for more than one person or by a company, please make sure all names are indicated. Please send a copy of this form together with a copy of the bank transfer to the address above. Please make drafts payable to: “ESPNIC”.Transfer to be made to: UBS, Geneva Branch, Rue desNoirettes 35, CH-1227Carouge, SwitzerlandSwift Number : UBSWCHZH80A, IBAN n°: CH320024024016472160E Account No: 0240-164721.60E
All bank charges are the responsibility of the payee and should be paid at source in addition to the membership fees.

Full name of the payor

BankBranch

Please note your membership will only be activated after authorization of the payment or confirmation that funds have cleared.

Signature:Date (dd/mm/yyyy):