Membership Form Membership Fee: Renewable every 1st January of each yearMiżata tas-Sħubija: Li tiġġedded fl-ewwel ta' Jannar ta' kull sena €14.00 Payment of Membership FeeĦlas tal-Miżata Payment using BOV Mobile to 79815671 ORTibgħat il-miżata billi tuża BOV Mobile għan-numru 79815671 JEW through a bank transfer or by internet bankingpermezz ta' bank transfer jew internet banking Details for a bank transfer or payment by internet banking:Dettalji għal bank transfer Coeliac Association - Malta jew għall-internet banking: Bank of Valletta plc, 184, Naxxar Road, San Gwann IBAN:- MT05VALL22013000000040023463833 BIC-SWIFT CODE:- VALLMTMT Account Number: 4002 3463 833 Personal DetailsDettalji Personali Name and SurnameIsem u Kunjom ID Card NumberKarta tal-Identità Insert parent’s details if coeliac is under 18 Niżżel id-dettalji tal-ġenitur jekk is-coeliac m’għandux 18-il sena Child's Name(optional)Isem it-tifel/tifla ID Card Number(optional)Karta tal-Identità Coeliac’s Date of BirthData tat-twelid tas-Coeliac Date Month Year Age when DiagnosedEta’ ta’ meta saret id-Djanjosi AddressIndirizz Address 1 Address 2 TownBelt Post CodeKodiċi Postali TelephoneTelefown MobileMowbajl EmailEmajl Medical DetailsDettalji Mediċi Consultant’s NameIsem il-Konsulent Date when DiagnosedData ta’ meta saret id-Djanjosi Date Month Year Has Coeliac been diagnosed by a Biopsy?Lis-Coeliac Saritlu Biopsy? YesNo Date when Biopsy was carried outData tal-Biopsy Date Month Year Copy of the biopsy reportKopja tar-riżultat tal-Biopsy If the Coeliac suffers from any other condition related to Coeliac Disease, please give details(optional)Jekk is-Coeliac ibati minn xi kundizzjonijiet oħra relatati mas-Coeliac Disease, agħti d-dettalji NewslettersDettalji Mediċi State language preferenceB’liema lingwa tippreferi taqra n-newsletter? EnglishMaltese Do you wish to receive medical information (only in English)?Tixtieq informazzjoni medika (bl-Ingliż biss)? YesNo How do you wish to receive newsletter?Kif tixtieq tirċievi n-newsletter? By emailBy post Do you wish to have a printed version in a larger font?Tixtieq tirċievi newsletter ipprintjata b’ittri akbar? YesNo
