Membership Form

INTERNATIONAL COLLEGE OF CARDIOLOGY

Prof Dr Daniel Pella, MD, PhD, FICC/ Prof Dr Jan Fedacko,MD,PhD, FICC
Email. Daniel.pella@upjs.sk tel 421 905340945, www.iccsk.com

The Executive Director

International College of Cardiology

Name. Mr/Mrs/Dr/Prof------------------------------------------------Age         Sex
Qualifications………………………………………………………………………….
Address:-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Tel                                               Fax                              email--------------------------

Affiliations---------------------------------------------------------------------------------------------

Current Work/Interest---------------------------------------------------------------------------------

Proposer’s; Dr R B Singh or…..

I wish to be a Life member of the International College of  Cardiology.I promise to follow the Byelaws of this organization.
My life membership (Euro.300.00)+fellowship fee(Euro.50.00) total fee Euro..350.00 is enclosed.(Nonrefundable)
Draft/Cheque No…………………..dated………….           (Fee is nonrefundable)
My corporate membership fee Euro.1000.00 Overseas
Company is enclosed. International members should send their fee to Dr Daniel Pella.

Signature.-----------------------------------Date……………………….

Decision of the Executive Director: Accepted/ Rejected. Accepted, Date…………..

Executive Director/Secretary General