|
APPLICATION FORM FOR MEMBERSHIP OF ISGE
MAIL OR FAX TO:
ISGE SECRETARIAT
SPAARNE HOSPITAL
P.O. BOX 1644
2003 BR Haarlem,
THE NETHERLANDS
TEL: 31-23-528 2686
FAX: 31-23-547 0881
Email: isgeoff@euronet.nl
PLEASE TYPE
NAME: _________________________________________________
ADDRESS: ______________________________________________
CITY: __________________________________________________
STATE: __________________________
COUNTRY: __________________________________
ZIP CODE: ____________________
TEL: ______________________________
FAX: _______________________________
SUBSCRIPTION: (CIRCLE those desired)
Annual Membership $75.00
Life Membership $750.00
Developing Countries Membership: $40.00*
Corporate Membership: $2000.00
Subscription to Journal: US $65.00
Associate Membership: scientific US $50.00, paramedics US $50.00, industrial individual US $250.00
Subscription to “Gynecological Endoscopy” $65.00
TOTAL SUBSCRIPTION:
$ US
METHOD OF PAYMENT (Circle one)
VISA MASTERCARD AMERICAN EXPRESS DINERS CLUB CHECK
(Check is payable to ISGE and only in US$)
Card Number: _________________________________
Exp Date: ___________________________
Signature: ____________________________________________________
ISGE Holland Secretariat Email: isgeoff@euronet.nl
ISGE USA Office Email: isge@nashville.com
|