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International Society for Mountain Medicine - VIWCMM regform

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International Society for Mountain Medicine - VIWCMM regform
VIth World Congress on High Altitude Medicine
Registration Form
(Deadline: 1 June 2004)
PLEASE COMPLETE (PRINT OR TYPE) AND FAX OR MAIL ALONG WITH YOUR PAYMENT, TO THE ADDRESS INDICATED BELOW
Mail or Fax this Form to:
International Society for Mountain Medicine,
5390 N Academy Blvd, Ste 310, Colorado Springs, CO 80918 USA
Phone +1-719-572-1372
Fax +1-719-572-1514, 1-800-967-7494 (USA only)
Email: membership@ismmed.org
I. I
DENTIFICATION
(Please print on computer or type)
Please complete this section carefully. The information you provide will help us to correspond with you efficiently.
Last Name: ________________________ First Name: _____________________ Degree: ______
Institution: _____________________________________________________________________
Address: _______________________________________________________________________
Street: ________________________________________________________________________
City: _____________________________ State/Province: _________ Country: _______________
Postal/Zip Code: _________________ Tel.(day): ________________ Fax: __________________
Email address: __________________________ First Name for Badge:_____________________
II. R
EGISTRATION
(in US dollars)
Regular $400 ____
ISMM Member $350 ____
Student $250 ____
From Less developed Country
(See list at www.ismmed.org/gdp.htm)
$300 ____
Accompanying Person $200 ____
III. P
AYMENT
Registration Fee for Participant
$______
Registration Fee for Accompanying Person
$______
ISMM Membership
(see www.ismmed.org/ismm_membership.htm)
$______
Total
$______
M
ETHOD OF
P
AYMENT
q Option 1: Credit Card:
I hereby authorize ISMM to debit my credit card account for the total amount indicated above.
This
charge will appear on your credit card statement as "Wilderness Medical Society", which is
processing these charges for the ISMM. You will receive a receipt from the ISMM at the conference, or by
email if you wish.
q Visa
q MasterCard
Card Number: _________________________________Expiration Date:_________
Cardholder Name: ________________________
Signature of Cardholder: ___________________
q Option 2: International Money Order
These must be in U.S. currency only, payable to ISMM. Your name and address must be clearly indicated.
q Option 3: Check
(for US delegates)
These must be made payable to ISMM. If you are sending a personal check your name and address must be
clearly shown on the front of the check.
Note: June 15
th
, 2004 is the deadline for registration fee refund (less 20% administration fee)





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