ISGE Membership Application

The most important part of the ISGE is you, the members. Without the participation of the members there would be no organization and no one place in the World for the exchange of ideas and techniques of gynecologic endoscopy. In order to keep this Society thriving it is important that we gain new members. If you are not a member, please fill out the form on the next page and submit it as soon as possible. If you are a member and know of someone who would be interested in membership, please give them the form. The membership form is also available on the ISGE website at http://www.isge.org 

APPLICATION FORM FOR MEMBERSHIP OF ISGE MAIL OR FAX TO:

ISGE Secretariat
PO Box 310
Morphett Vale
South Australia 5162
Phone: 61 8 8326 0222
Fax: 61 8 8326 0622
E-mail: rtoshea-isge@adam.com.auPLEASE TYPE:

NAME: ________________________________________

ADDRESS: ___________________________________________

CITY: _______________________________  STATE/PROVINCE: _____________________

COUNTRY: _________________________  ZIP CODE: _____________________

TEL: _______________________   FAX: _________________________

SUBSCRIPTION: (Please verify costs before submitting payment)Annual Membership $100.00 / Life Membership $950.00 / Developing Countries Membership $60.00* / Corporate Membership Upon Request
Subscription to Journal: US $65.00
Associate Membership: scientific/paramedics US $60.00 / industrial US $350.00

TOTAL SUBSCRIPTION:
$ US _____________________

METHOD OF PAYMENT  (Circle one)

VISA - MASTERCARD -  AMERICAN EXPRESS - DINERS CLUB - CHECK (Check is payable to ISGE and only in US$)

Bank transfer (please mention name and "ISGE reg. fee")
ABN-AMRO Bank, Binnenweg 5-9, 2101 JA Heemstede, The Netherlands.
US$ acct #: 53.31.12.095, Swift#: ABNANL2A, of: St.Endogyn, Haarlem, Netherlands

Card Number: _____________________________________  Exp Date: _____________________

Signature: ____________________________________________________

ISGE Holland Secretariat Email: isgeoff@euronet.nl   ---   ISGE USA Office Email: isge@nashville.com