Membership Application Renewal Form (DOC) by wuxiangyu

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									                                          Membership Application / Renewal Form 1

                    KETTIL BRUUN SOCIETY
    FOR SOCIAL AND EPIDEMIOLOGICAL RESEARCH ON ALCOHOL

                  (THE MEMBERSHIP FEE IS CHANGED FROM USD TO EURO)

Name:
Affiliation:


Mailing address:


Te lephone:                  office:                                            home:
Te lefax:                                                                       E-mail:

                             AGE: ______________________ GENDER____________________________



A. Membership fees:                    € 25 per year                                        € 75 per year
                                       (from personal resources)                            (from institutional resources)



I will pay for
                                       ( ) € 25 for 2011           ( ) € 50 for 2011-2012                    ( ) € 75 for 2011-2013
(from personal resources):

I will pay for
                                       ( ) € 75 for 2011           ( ) € 150 for 2011-2012                   ( ) € 225 for 2011-2013
(from institutional resources):

 I am unable to pay the fee, but wish to become a member.


Rene wal only: In addition to the payments above, I am also paying for: ( ) 2009   ( ) 2010


Total amount to pay:                      EURO



B. Payment (Please, prefer the Visa/MasterCard alternative if possible).
                                            2
Please charge my ( ) Visa ( ) MasterCard no. :                                               Expire date:

Name of the cardholder/Signature :




                                         Alternative ways to pay (please avoid checks due to high bank fee):

Direct Deposit to bank accounts:                                   Checks made payable to “Kettil Bruun Society” to:
Kettil Bruun Society / SIRUS                                       Elin K Bye
Nordea Ban k Norway                                                SIRUS, POBOX 565
Postbox 1166, Sentru m                                             0105 Oslo, Norway
0107 Oslo, Norway                                                  Fax: 004722340401
Account No. 6080.05.28685
IBA N: NO18 60800528685
BIC: NDEANOKK




1
 Renewal of membership: Those of you who have not yet paid for 2008-2010 are asked to do so in connection with this
payment. If you do not know your current payment status, please contact KBS Treasurer Elin K. Bye for an update (e-
mail: ekb@sirus.no ).
A COPY OF ALL APPLICATION FORMS MUS T BE E-MAILED/MAILED TO:


                              Elin K. Bye
         S IRUS , PO BOX 565, 0105 Oslo, Norway (ekb@sirus.no)

								
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