INDIVIDUAL

INDIVIDUAL MEMBERSHIP FORM FOR INCS

	:
Title	:
First Name	:
Middle Name	:
Last Name	:
Institution	:
Address	:
City	:
Country	:
Occupation and Duties	:
Phone	:
Fax	:
E-mail	:
Please write your specific comments, if any	:

Membership fees
	One year	Two year	Three year
Individuals from industrialized countries	$ 75 (Є 53)	$ 140 (Є 117)	$ 200 (Є 167)
Individuals from developing countries	$ 50 (Є 42)	$ 90 ....(Є 75)	$ 135 (Є 113)
Individuals from poor countries	$ 25 (Є 21)	$ 40.... (Є 34)	$ 55.... (Є 46)

PAYMENT METHOD

Corresponding membership fee $ or (Є )

Credit card

Visa Master Other

Card no. / / / Exp. date : / CVV no. :

Card holder: Signature :

Bank transfer to
......Garanti Bankası Ege Üniversitesi Ofisi, Bornova, Izmir, Turkey
...... INCS account no. : 524-9095092 for EURO ( Є), 524-9095093 for USD ($)

Bank receipt is attached to the corresponding application form.
......Ps : Please don’t send any personal check.

Print This Page

Please copy the filled form and then
fax (+90 232 377 1024) or mail it to the following address:
Turan ÜNAK, INCS President, Ege University, Faculty of Science,
Department of Chemistry, Division of Nuclear Chemistry, Bornova, Izmir 35100, Turkey