Membership registration form

(Please save the form as txt file to your desktop, fill it inn and fax it or send it by e-mail to: Merete.Allertsen@isf.uib.no)

Category of membership: (please tick below)

Individual ___

Student ___

Non-profit Institution ___

Corporate ___

Family name:

First name:     

Title:

Postal Address:

Tel:

Fax:

E-mail:

Or

Organisation name

Lead contact person

Address

_________________________________________________________________________

Please register me / my organisation (delete as appropriate) as a member of the International Society on Priorities in Health Care.

I consent to my name being recorded in a published list of members of the Society. This list may be used for publicity purposes / advancing the interests of the Society (eg, seeking funding support of international organisations).

Yes / No                                        

Name/signature:

If relevant: I seek consideration of the Management Committee for reduced or waived fees on the following grounds:

(please attach relevant material for Management Committee consideration).

To register with the Society please return the form by fax, mail or e-mail to

Merete Allertsen

Division for Medical Ethics

Institute of Public Health and Primary Care

University of Bergen

PB 7804

5020 Bergen

Norway

Phone: +47 55586135

Fax: +47 55586130

Email: Merete.Allertsen@isf.uib.no