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International Society for Mountain Medicine - subs ismm

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International Society for Mountain Medicine - subs ismm
INTERNATIONAL SOCIETY FOR MOUNTAIN MEDICINE
APPLICATION FOR MEMBERSHIP and MEMBERSHIP RENEWAL FORM
You have the following possibilities to pay your membership fees: 1. By credit card: please use the
form below or 2. Send a Eurocheck (in Swiss Francs) in favour of the ISMM directly to the
Membership Secretary 3. Give your bank the order to transfer the appropriate equivalent amount to our
account: nr.CO-257.980.0, Swiss Bank Cooperation, CH-1211 Geneva 4, Switzerland. 4. Swiss
members can pay by postal check to PC 12-172-9 (or Swiss Bank Cooperation, CO-257.980.0).
Renewal of membership is due on the 1st January each year. If fees are not received on time,
membership will cease, after a single reminder.
USE FOR NEW APPLICATION & FOR MEMBERSHIP RENEWAL ON 1st JANUARY EACH YEAR
PLEASE USE BLOCK CAPITALS.
Name and Position/Affiliation: _____________________________________________________
Address:
Phone:
Fax:__ ____________________E-mail: _________________________
Membership category: [ ]member (40 US$ or 50 Swiss Fr)
(tick as appropriate)
[ ]residents / assistant doctors (30 US$ or 40 Swiss Fr)
[ ]group member (170 US$ or 200 Swiss Fr)
[ ]student member (25 US$ or 30 Swiss Fr)*
[ ]complimentary membership (apply to the President of ISMM in writing)**
Payment by: Eurocheque [ ] Credit card [ ] Bank order [ ] Postal cheque (in CHF for Swiss members) [ ]
(tick appropriate)
Signature:
Place and date: _______________
* student member: anyone enrolled in an academic curriculum leading towards a degree.
** complimentary membership is available for those who experience difficulty in paying their subscription
Credit Card Form (to be completed by those who pay with a credit card):
Name:
Address
City/Country_________________________________
Please charge my credit card for the amount of _________ Swiss Francs for the membership fees for the ISMM.
AMEX:[ ]MASTERCARD/EUROCARD: [ ]VISA: [ ]
No.:
Exp. Date: __________
New membership:[ ] (y/n)
Signature:
___________________________ Place and date:__________________
Send to: Dr.Bruno DURRER, Membership Secretary of the ISMM, Arztpraxis CH 3822 Lauterbrunnen,
SWITZERLAND, Fax:++41 33 856 26 27, email: B.Durrer@popnet.ch





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