National 01

Name:*

First Name Required Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Name of organization : Name of organization is not valid

Position / Function of representative : Position / Function of representative is not valid

Department: Department is not valid

Telephone number:* Telephone number is Required

Email:* Email is Required

Website URL: Website URL is not valid

Telemedical activities: Telemedical activities is not valid

Special interests: Special interests is not valid

Upload Logo/Photo (jpg, png, 16:9 format): Upload Logo/Photo (jpg, png, 16:9 format) is not valid

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Select Payment Method

Stripe Payment by wire transfer

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Beneficiary:
ISfTeH
Postfach 757, Dufourstrasse 49, 6301 Zug
4052 Basel / Switzerland

Bank: UBS AG
IBAN (International Bank Account Number):
CH12 0027 3273 2760 0160 D
Bank SWIFT Code: UBSWCHZH80

No val Please fix the errors above

Pay ISfTeH

$100 / Year

	National 01 – Initial Payment $100 / Year	$100.00
	Total	$100.00

National 01 – Initial Payment

$100 / Year

$100.00

Total

$100.00