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Membership Pledge


    
    

    
    
I would like to join the International Society of Prenatal and
    Perinatal Psychology and Medicine




    
    
Last name:
      _________________________________________________________________________

    
    
 

    
    
First name:
      _________________________________________________________________________

    
    
 

    
    
Title / Profession: ________________________ Date of birth: (M/D/Y)
      __________________________

    
    
 

    
    
Professional appointment:
      _______________________________________________________________

    
    
 

    
    
Home address:
      _______________________________________________________________________

    
    
 

    
    
Home telephone number / Fax:
      ___________________________________________________________

    
    
 

    
    
Professional address:
      ___________________________________________________________________

    
    
 

    
    
Professional telephone number / Fax:
      _______________________________________________________

    
    
 

    
    
Date / Signature :
      ______________________________________________________________________

    
    
 

    
    

    
    
Please indicate one of the following:

    
    
O I want to get a new ISPPM Member

    
    
O I want to renew my ISPPM Membership for (year) _____________

    
    
Please indicate one of the following:

    
    
O ISPPM Membership with the Journal EUR 140,-- plus EUR 25,-- for
      airmail delivery outside Europe

    
    
O ISPPM Membership without the Journal EUR 100,--

    
    
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Payment by 

    
    

      

        
        
        
O VISA - Card 

        
        
        
O MasterCard 

      

    

    
    
(no other credit cards can be accepted) 

    
    
Details: Name: _______________________________________ 

    
    
(as it appears on the card) 
  
  

    
    
Card Number:    
        

    

      

        Expiry Date (mm/yy): ________ 
        CVV2 or CVC2 
        
      

    

    

      

        
        
        
Signature: ________________________ 

        CVV2 (VISA-Card) = Card Verification Value
        CVC2 (MasterCard) = Card Verification Code You will find this number on
        the backside of your credit card into the signature field. The last 3
        digit after the repeated card number is the Card Varifivation Value
        respectively Code.
      

    

    
    
O Check enclosed. Please make check payable to: ISPPM, 69118 Heidelberg 
NB: For payment by cheque order please add EUR 15,-- for bank charge. You
      will be invoiced for any outstanding balances. 

    
    
  

    
    
Please copy this page and return to:

    
    
The Secretary of the ISPPM

    
    
A. & J. Bischoff

    
    
Friedhofweg 8

    
    
D - 69118 Heidelberg

    
    
GERMANY

    
    

    

    

      
Back to homepage

    

    
    
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ISPPM-Secretary

    
A. & J. Bischoff

    
Friedhofweg 8, D - 69118 Heidelberg, Germany

    
Phone: +49 6221 892729 Fax: +49 6221 892730 

    
E-mail: <secretary@isppm.de>

    
    
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Last updated on: May, 28, 2006 by A.Bischoff