To be completed, printed and returned to: PD Dr. med. Othmar Schubiger Neuroradiologie Klinik im Park Seestrasse 220 CH-8027 Zürich Fax: +41 1 2092138 E-mail:schubiger.o@bluewin.ch Membership category Full Associate Junior Emeritus Corresponding Honorary Mr Mrs Ms Dr Prof. First name Family name Please fill in your data only if they have recently changed. Indicate if this is your private address. New Institution New Department New Street and number New Post-code and town New Country New Phone number New Fax number New E-mail address VISA Eurocard Amount to be charged EURO Name of cardholder Card number CVV2 code Exp. date Date Signature

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