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Nuevos socios SEIP
Cuota anual 55€
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Email
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Nombre
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Apellido 1
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Apellido 2 (si no, poner -)
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DNI
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Dirección
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Localidad
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Número de teléfono
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Lugar de trabajo
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Hospital Público
Hospital-Clínica-Consulta Privada
Atención Primaria
Investigación
Otro
Nombre del centro de trabajo
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Ciudad
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Provincia
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Cargo
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Pediatría
Infectología pediátrica
MIR
Máster
Becario
Otro
Nº de colegiado
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Datos Bancarios (completar abajo)
Cuota anual 55€
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IBAN (ES xx)
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Entidad (XXXX)
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Oficina (XXXX)
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DC (xx)
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Cuenta (10 dígitos)
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