• 45 East Deloney Avenue PO Box 1552
  • (+061) 307-733-3005

Rue du Commerce 96, C-Block 6th Floor, 1040 Brussels, Belgium.

+32-(0)2-536.08.80

MEMBERSHIP FORM

MEMBERSHIP FORM

  • NAME SURNAME :
  • INSTITUTION:
  • ADDRESS:
  • TEL:
  • FAX:
  • E-MAIL:

I would like to become a member of EGPA and settle the annual subscription fee amounting to

375 € as Corporate Member
75 € as Individual Member
400 € as EAPAA Member
  • DATE :
  • SIGNATURE:
Contact Person: Dr Fabienne Maron
IIAS Scientific Director
96 rue du Commerce - B-1040 Brussels – Belgium
Tel 32-2-536 08 84 Fax: 32-2-537 97 02 - e-mail : f.maron@iias-iisa.org

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