Membership form 2012
Personal details (please do not mix your working address and private address)
Family / Last name *
First Name *
Title*	select your title Dr. Prof. Mr. Ms. Mrs
Institute
Department
Street and number *
Postal code and city *
Country *
E-mail *
Telephone
Fax
RIZIV nummer - numéro INAMI
Date of birth	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
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I want to renew / apply for BSRM membership 2012
Amount in euro including 6% VAT
Profession	55 EUR - Clinician 55 EUR - Biologist 55 EUR - Psychiatrist 55 EUR - Other 25 EUR - Nurse 25 EUR - Lab technician 25 EUR - Resident in training 25 EUR - Psychologist 25 EUR - Midwife
Language	Dutch French Other
__________________________________________________________________________________________ Invoice details (if different from personal details - invoice will be sent after receipt of your membership fee.
Title + First name + Last name
Institute
Department
Street and number
Postal code and city
Country
Vat N°
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Payment policy
Full payment has to be made to the BSRM account 310-1263178-33 with reference:“Name + membership 2012”. IBAN number: BE79 3101 2631 7833 • BIC: BBRUBEBB • Bank: ING.
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