Membership application – IPNET – International Porphyria Network

Membership type(Required)

Full member (230 €)

Associate member (115 €)

Individual member (25 €)

Corporate member (12.000 €)

Name(Required)

First name Last name

Title

Birthday(Required)

Institution / Clinic(Required)

Address of the Institution / Clinic(Required)

Street + Nr. Address Line 2 City ZIP Code Country

Private Address(Required)

Straße + Nr. Address Line 2 City ZIP / Postal Code Country

Phone(Required)

E-mail(Required)

Consent(Required)

I confirm that the centre meets the requirements for membership as set out in the Ipnet statutes and I understand that evidence may be requested to verify this

Consent(Required)

I confirm that the centre/organisation meets the requirements for membership as set out in the Ipnet statutes and I understand that evidence may be requested to verify this

Consent(Required)

I confirm that the individual meets the requirements for membership as set out in the Ipnet statutes and I understand that evidence may be requested to verify this

Consent(Required)

I confirm that the company meets the requirements for membership as set out in the Ipnet statutes and I understand that evidence may be requested to verify this

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