ISCOWA membership form

To become a member of ISCOWA, please print out and complete the following form, and return to:

ISCOWA
Tempelierhof 5
3544 NA Utrecht
The Netherlands.

REGISTRATION FORM

I herewith declare to want to become a member of ISCOWA,

The International Society for the Environmental and Technical Implications of Construction with Alternative Materials, and to observe its Statutes.

Name:

Affiliation:

Full Address:

Telephone:

Telefax:

E-mail:

Signed at (place):

Date:

Signature:

Yearly contribution fee: € 50, to be deposited on account nr. or by payment via your American Express, MasterCard or VISA credit card, see below.
Special offer: if you choose to pay the membership fee for 2011, 2012 and 2013 simultaneously you will get a discount of 10%. Please pay € 135 if you want to use this possibility.

PAYMENT OF MEMBERSHIP FEE

I will pay my membership fee of EUR 50.- (= ca. UK£ 42 / US$ 63 ) for 2011 as follows:
[ ]Yes, as new member, please send me the ISCOWA/Wascon 2003 CD-rom for only EUR 25. (please check box)

[ ]Preferred method: I will deposit € 50.-- (or € 135 for 3 years) into ISCOWA's International Bank Account Number (IBAN): we will send you an invoice with our bankaccountnr. after reception of this form.

[ ] Charge my [ ] American Express or [ ]VISA or [ ]MasterCard credit card for [ ] € 50 (year 2011) or [ ] € 135 (years 2011, 2012, 2013) + € 25 for the CD-rom if checked.

Please fill in your credit card information:

Credit Card nr:

(the 3 extra digits at the back of your credit card)
CVC-code:

Expiration date:

Name as stated on the credit card:

Address to which the credit card is registred:
Please include ZIP or postal code!

Date:

Place:

Signature:

DO NOT SEND US YOUR CREDIT CARD INFORMATION BY INTERNET E-MAIL, THIS IS NOT A SECURE CHANNEL. USE POSTAL SERVICES ONLY!