New Member Application and Upgrade Form
Transcription
New Member Application and Upgrade Form
Membership New Member Application and Upgrade Form AOTrauma membership fee 1 year Membership package: 2 years Membership package: 3 years Membership package: CHF 100 CHF 180 CHF 270 USD 100 USD 180 USD 270 ding Join the lea ma and global trau or thopedic EUR 80 EUR 144 EUR 216 communit y Prerequisites I herewith confirm that I meet the AOTrauma membership prerequisites: 1: Are you a Musculosceletal professional? yes no 2: Have you successfully completed an AO principles course? yes no Please provide the course name, date and location. (For researchers: please provide the musculoskeletal/trauma related research activity you are involved in.) What is your main reason for becoming an AOTrauma member? Access to educational and training resources Reputation of AOTrauma as a leader in musculoskeletal trauma care Being part of a global network/networking Career development opportunities Access to member benefits Being an AOTrauma Faculty Interested in Fellowship application Previously associated with AOTrauma as AO Alumni Other How did you learn about AOTrauma? Recommendation by a colleague AOTrauma presence at a global congress Participation in an AOTrauma course Recommendation by an industrial partner Through the local country council Printed advertisement Internet search Other Applicant information First Name Last Name Date of birth: dd/mm/yyyy E-mail address Hospital name Department Street Address / P.O. Box Postal Code / Zip City Payment options Credit Card Visa Mastercard Country American Express Bank Transfer Please send your payment to the following bank account: CREDIT SUISSE, 7270 Davos Platz, Switzerland Account No: 614225-31 Clearing No*: 4835 IBAN: CH18 0483 5061 4225 3100 0 SWIFT: CRESCHZZ Account Holder: AO Stiftung, Grabenstr. 15, CH-7000 Chur Name as it appears on credit card Credit card number Security number (Visa/MC—3 numbers on back; AMEX—4 numbers on front) Expiration Date (mm/yy) § Cash (only in case of direct cash payment at an AOTrauma booth) * Clearing No. = BLZ = Sort Code = ABA No. = Routing No. •P lease enter a payment description as follows: “AOTrauma membership fee—Month/Year” • If you are making a payment on someone’s behalf, please include the member’s full name in the payment description. Member-exclusive benefits—reasons to join the AOTrauma network Get connected through the Member directory Access free e-books and other book discounts Advance knowledge through Injury journal and Journal of Perioperative practice Explore Primal Pictures, 3D human anatomy Please email your completed form to [email protected], fax it to +41 81 4142 283, or post it to: Benefit from Fellowship opportunities Access educational videos and lectures Share knowledge through CaseForum Choose from a variety of Ovid online journals And access other special offers and discounts AOTrauma Clavadelerstrasse 8, 7270 Davos, Switzerland For more information: Phone +41 81 414 21 11 | www.aotrauma.org