Modification form

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The form below may be used to inform the G.M.F.W. of changes in your personal data. If you want to receive the newsletter by e-mail, simply indicate an e-mail adress. If you don't you will recieve the newsletter at the adress indicated, unless you live outside the Netherlands and Belgium. If you fill out your name correctly, it suffices only to fill in the values that must change. The modifications will be reported back to you as soon as possible (if possible by e-mail).

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Options

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Internet
This information may be used as public information at this site
This information is to remain strictly personal



Adress
G.M.F.W. mail has to be sent to my home adress
G.M.F.W. mail has to be sent to me by e-mail
G.M.F.W. mail has to be sent to the institute

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Name

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	First letters:
	Title(s):
	Name:
	Extension:

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Home adress

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	Street:
	Housenumber:
	Postal code:
	City:
	Land (if not the Netherlands):
	Telephone number:

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Institute
(optional)

If you want to indicate a Post Office Box number, please insert the word "P.O. Box" in the "Street" box.

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	Institute:
	Department:
	Street:
	(P.O. Box) number:
	Postal code:
	City:
	Land (if not the Netherlands):
	Telephone number:

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Remaining

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	Fax:
	E-mail adress:
	Internet-site: