INDUSTRIAL MEMBERSHIP FORM FOR INCS

Name of Company
:
Web: http://
:

Responsible Person

:
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
Industrial from industrialized countries $ 750 (Є 530)
$ 1400 (Є 1170)
$ 2000 (Є 1670)
Industrial from developing countries $ 500 (Є 420) $ 900 (Є 750) $ 1350 (Є 1130)
Industrial from poor countries $ 250 (Є 210) $ 400 (Є 340)

$ 550 (Є 460)


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.

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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