秘書處業已於95年12月15日完成辦理2007
APSSM/ISSM Joint Membership會費繳納程序。相信已繳費之APSSM/ISSM會員們應已陸續接到由APSSM秘書處所回覆之確認函及收據憑證。
若已繳費之會員至今仍未收到收據的話，煩請通知秘書處以利轉知。
提醒您，身為APSSM/ISSM Joint Member之基本權益如下：
| • |
Subsidy of 50% ISSM/APSSM membership by APSSM (provided payment made to APSSM
secretariat by 20th December, 2006). |
| • |
Opportunity to apply for APSSM travel and research grants. |
| • |
Free Journal of Sexual Medicine (6 issues) per year. |
| • |
Free ISSM news bulletin (3 issues) per year. |
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Free APSSM news letters. |
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Free access to ISSM website. |
如果您錯過了本次的集繳活動（12月20日後視為逾期），而您仍有意願想要加入成為2007 APSSM/ISSM Joint
Member的話，您只需填寫附件一表格，按內容指示直接將費用逕付ISSM Secretariat即可。
APSSM秘書處並特別來函提醒，詳內容如下：
Dear TAA Secretariat,
Please in future, don’t send any individual remittance as the bank
charges per transaction is USD25.00.Therefore we only received
USD30.00 for your membership payment on behalf of Dr Wai–Yan Wong.
APSSM do not have the budget to subside huge exchange losses and
bank charges. For individual payment we asked members to pay
directly to ISSM and fax/ email us the receipt from ISSM to be
included as APSSM member. I hope you understand our situation.
Attached please find a copy of the authorization to debit of credit
card for ISSM.
Thank you & kind regards,
Hui Meng TAN, FRCS(Edin), FRCPS(Glasg).
Consultant Urologist
Adjunct Professor, Faculty of Medicine, University of Malaya
Secretary General, Asia Pacific Society for Sexual Medicine (APSSM)
and
Asia Pacific Society for Study of the Aging Male (APSSAM)
1, SS12/1A, Subang Jaya 47500 Petaling Jaya, Selangor
MALAYSIA.
Tel: 603 - 5630 6777
Fax: 603 - 5630 6571
Email: perandro@streamyx.com
另外，學會對於本次第一次試辦之美金收費方式，如果造成您的不便，敬請見諒為荷！下年度之繳款方式將恢覆原來之辦法辦理，謝謝大家。
| International Society for Sexual Medicine |
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| APPLICATION FORM - ISSM MEMBERSHIP 2007 |
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Prof. / Dr. / Mr. / Mrs. |
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First Name + Initials |
(please circle) |
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| I would like to
receive mail to my Home- or Institute address (please
circle) |
| Institution Address |
Home Address |
| Institution |
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| Department |
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| Street |
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| City |
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| Postal Code |
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| Country |
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| Telephone |
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| Fax |
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| Email |
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| Street |
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| City |
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| Postal Code |
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| Country |
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| Telephone |
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| Fax |
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| Email |
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I am:
□ UROLOGIST □ OB/GYN ANDROLOGIST □ PSYCHIATRIST
□ RADIOLOGIST □ OTHER:………………………………………………
Percentage of professional activity devoted to sexuality and
impotence research ………………………………………%
Names and email- addresses of 2 (two) members of ISSM endorsing
your moral and professional standard |
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1. ………………………………………………… |
2. ………………………………………………… |
| Professional degree: |
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| Main publications: |
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Please attach a copy of your CV
Your application will be reviewed by the board of the ISSM
The 2007 membership includes a subscription to the Journal of
Sexual Medicine. |
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PAYMENT: Please tick: |
Conversion USD / EUR: based on daily exchange rates. |
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□ Full Membership 2007
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EURO 85,00 |
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□ Trainee Membership 2007 |
EURO 40,00 (provide a letter of verification from your professor
or mentor) |
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□ Voluntary donation Adrian Zorgniotti Fund EURO ……… (minimum:
EURO 50,00). |
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CARD HOLDER’S INFORMATION |
| Name Cardholder: |
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| City: |
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| Country: |
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I hereby authorise the ISSM Executive Office to debit my
creditcard for the Grand Total amount indicated above. |
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Credit Card：□ Visa □ Eurocard / MasterCard □ American
Express |
| Card Number: |
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01 |
02 |
03 |
04 |
05 |
06 |
07 |
08 |
09 |
10 |
11 |
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13 |
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| Expiry Date: |
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| Validation Code (CVC) VISA
and Eurocard/Mastercard: |
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| last 3 digits on signature strip (reverse side of the
card). |
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□ Payment by wire-transfer for total amount of EUR
…………………………
into bankaccount number |
40.43.97.077 with ABN-AMRO Bank, Zeist,
The Netherlands. Please indicate “ISSM”.
Swift code (BIC): ABNANL2A
IBAN: NL04ABNA0404397077 |
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