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Please send the application to:

Anaesthesia in Developing Countries e.V.

c/o Center for Anesthesiology

Robert-Koch-Str. 40

37075 Göttingen

Membership application

I hereby confirm my membership in the association “Anaesthesia in Developing Countries e.V.” The annual membership fee is €25.50 and will be debited from my account by you using the enclosed direct debit authorization.

The membership fee is tax deductible. The deposit slip or bank statement serves as proof of payment.

Last name, first name, title:

Street:

Postal code, city:

Email address:

Date Signature

DIRECT DEBIT AUTHORIZATION FOR MEMBERSHIP FEES FROM 2004 €25.50

I hereby revocably authorize the association “Anaesthesia in Developing Countries e.V.” to collect the annual membership fee by direct debit. The payment shall be collected from my account at the / the

financial institution:

Account no.:

Bank code:

Account holder:

First and last name

If my account does not have the necessary funds, the financial institution managing the account is not obliged to honor the payment.

Place, date Signature