EUROPEAN ASSOCIATION OF ORAL MEDICINE

President: Secretary: Treasurer:

Prof Marco Carrozzo Assoc. Prof. Nikololaos Nikitakis Prof Michael Escudier

UK Greece UK

Personal Details

Title:
First Name: / Date of Birth:
Last Name: / Email:
Qualifications
Basic Dental
Qualification: / Other Qualifications:
Dental School at which you qualified: / Particular area of interest in Oral Medicine:
Contact Details
Home Address / Work Address
No./Apartment/
Street: / Name of Institution/
Business:
Town/City: / Number/Street:
County/State: / Town/City:
Postcode: / County/State:
Country: / Postcode:
Telephone: / Country:
Fax: / Telephone:
Fax:
Private Practice Address (if different from work address above)
Name of Institution/
Business:
Number/Street: / Telephone:
Town/City: / Fax:
County/State:
Postcode:
Country:
Oral Medicine Society of which you are a member:
References
(only required if not a member of an existing Oral Medicine society)
Reference 1
Name: / Telephone:
Email: / Fax:
Reference 2
Name: / Telephone:
Email: / Fax:

Payment Details: Membership is based upon calendar years

Name: ______

Address: ______

______

Method of Payment

£70 (80 euros) for 1 year OR £140 (160 euros) for 3 years

You may pay your dues in Pounds or Euros by either: -

1.  Cheque (sterling only please)

2.  Credit Card : sterling only

3.  Bank transfer: Bank details will be provided when individuals request to use this payment method

4.  PayPal via the EAOM website: http://www.eaom.eu/eaom-membership-new/how-to-renew-your-subscription

1. Cheque made out to European Association of Oral Medicine for 70 pounds sterling for one year or 140 pounds sterling for three years.

……………………………………………………………………………………………

2. Credit Card No:

Visa/MasterCard [NOT American Express]

Expiry date (m/y): Amount: £70 – 1 year

£140 - 3 years

3 digit security code:

Name on card: ______

Signature: ______Date: ______

Please send your completed form, indicating your method of payment (with accompanying cheque where appropriate) to the EAOM Membership Administrator, Mrs Josephine Carr, 4, Tanners Dean, Leatherhead, Surrey KT22 8RU or