IADIS MEMBERSHIP APPLICATION FORM

Please type or print clearly
First Name 					 Last Name 						
Title 			  
Department 												
University/Organization 																								
Address													
City 				Province(State)			P.Code/Zip				
Country			Telephone (      )			Fax				
email 													

IADIS Member Number (for renewals) 			 

Membership Fee     Euro 75

•	Membership includes 1 year journal subscription (on-line version).
•	IADIS Membership is valid for 12 months from the date of purchase. Members receive a discount registration rate for all IADIS conferences within this time frame.

Payment Method (Payment in Euro must accompany this form):

  Visa         Mastercard       American Express      	  CVC***					
Credit Card Number 					  Expiry Date					
Name of Cardholder 					  Signature					
*** See back of the creditcard: 3 digits following the card number
 Cheque (Payable to  IADIS)  
Cheque Number 				Bank			 Amount 				

MAIL  :IADIS					FAX:   +351 21 3151244
	    Rua Sao Sebastiao da Pedreira, 100, 3			email: secretariat@iadis.org
	    1050-209 Lisbon        Portugal