Become a Bapa-member – Specialist

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€50 EUR / One Time (for 1 year access, non-recurring)

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First Name *

Last Name *

Email Address *

Username (lowercase alphanumeric) *

Password (type this twice please) *

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Additional Info

Title *

Private Address *

Zip Code *

Place *

Telephone Number

Professional data

RIZIV/INAMI number (only for specialists and assistants)*

Function *

Specialism *

Hospital *

Hospital Address

Zip Code *

Place *

Billing Method

Credit or debit card

Billing Address

Street Address *

City / Town *

State / Province *

Postal / Zip Code *

Country *

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