Edizioni minerva medica order form for single site institutional subscription

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EDIZIONI MINERVA MEDICA
ORDER FORM FOR SINGLE SITE INSTITUTIONAL SUBSCRIPTION
Please download the order form, complete it and forward it with the attachments requested to the following email address:
subscriptions.dept@minervamedica.it
I wish to subscribe to the journal _____________________________________ Year ________
Type of subscription S M L XL
New Subscription Print online Print + online

Subscription Renewal Print online Print + online

Subscriber code no. ______________
Amount € ______________
Payment procedure
I paid on ______________
to EDIZIONI MINERVA MEDICA – C.so Bramante 83-85 – 10126 Torino, by:
 Bank transfer (copy enclosed)

Bank details: INTESA SANPAOLO Ag. 18 Torino, C.so Bramante 82, 10126

Torino – IBAN: IT45 K030 6909 2191 0000 0002 917 – BIC BCITITMM

Details of institution (all fields are compulsory)
Institute/Body/Company _______________________________________
_______________________________________
Address ________________________________
Post Code ____ City ___________ Province ___
Country ________________________________

Shipping Details (all fields are compulsory)
Institute/Body/Company _____________________________________
_____________________________________
Address ______________________________
Post Code ____ City __________ Province ___
Country _______________________________

Details of subscription administrator (all fields are compulsory)
Surname and First Name ______________________________ Tel. ____________________________
E-mail address_______________________________________ Fax ____________________________

I wish to receive a receipted invoice.  Yes  No

If affirmative, please provide a VAT number ____________________________
Personal details will be used for invoicing
The details transmitted which you, in accordance with Decree Law no.196/2003 authorise us to handle, will be used solely for commercial purposes and to promote our activities. Updates or cancellation of details should be requested from:
Edizioni Minerva Medica, Corso Bramante 83-85, 10126 - Torino.