ISFA MEMBERSHIP APPLICATION

 

Full membership in ISFA is open to all who have been professionally involved in apheresis and meet certain minimum requirements. Associate membership is available to anyone who is interested in the technology of apheresis or in clinical applications of apheresis. Individual membership in ISFA is individual not organizational, and is fully portable in the event of a change in employment. Dues for full are US$150 year. Associate (student) membership is open to any person regularly enrolled on a full-time basis in an institution of higher learning; the dues are US$75 per year (Journal is not included).

 

Check preferred mailing address: Home _____ Business _____

 

 

Last Name (Surname)                                              First Name                      Middle Initial                                      Degree(s)

 

Home mailing address

 

City                                                         State/Province                                    Country                                                 Zip Code/Postal Code

 

Telephone (include country and area codes)      Fax number                                   Email address

 

Company/Institution name                                                                                                Department (if applicable)

 

Company/Institution address

 

City                                                         State/Province                                    Country                                                 Zip Code/Postal Code

 

_____                Member: U.S. $150/yr. (open to those professionally engaged in the field)
_____                Associate member: U.S. $75/yr. (Does not include subscription to Therapeutic Apheresis)
                _______________________________________________________
                Instructor signature (required for Associate member)

 

METHOD OF PAYMENT

□ Check enclosed (Drawn on U.S. banks only) – Make checks payable to “The International Society for Apheresis”

□ Charge Card This serves to authorize that dues be charge to my credit card   □MC   □Visa   □AMEX 

Card #__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

 

Name (as it appears on Card)               Authorizing Signature                Expiration Date (MM/YY)

 

List one professional reference (students list an advisor):

Name___________________________________________________________________
Address_________________________________________________________________
City/State/Country ZIP _____________________________________________________

 

Please send Membership Application to:
The International Society for Apheresis, Headquarters Office
Department of Surgery, Shiga University of Medical Science
Seta Tsukinowa-cho, Otsu, Shiga 520-2192, Japan
Tel: +81(77) 548-2238            Fax: +81(77) 548-2240

Email: isfa@belle.shiga-med.ac.jp