Membership – Individual registration form

Home / Membership – Individual registration form

Please fill in the form here below and become a member today.

You can also download  our PDF CKIN Membership Application Form and return it to info@c-kin.org.

Personal information

First Name (required)

Last Name (required)

Email address (required)

Position (required)

Company / Institution (required)

Discipine (required)

Address Street / Box # (required)

City (required)

Zip / Postal Code (required)

State / Province (required)

Country (required)

Phone (required)

Fax (required)

Website

Date of birth

 

Membership type

Choose your subscription plan (required)

 

Payment

Please note that the payments are not automatically processed. You will be contacted soon.

Wire transfer

To be paid to Cancer & The Kidney International Network (C-KIN)

Bank details ING BELGIUM S.A. – Avenue Marnix, 24 - B-1000 BRUSSELS, BELGIUM
Account Number 363-1421228-24
IBAN BE81 3631 4212 2824
BIC BBRU BE BB

 

Human check! (required)
captcha