Membership Application

Instructions

The Membership Application may either be printed and mailed, or sent electronically. To complete this form, fill out your personal information, membership level, billing information, and provide a signature. If your qualifications are not evident in MEDLINE, please send a brief CV or titles of representative publications to the Executive Director. Membership level categories are described in more detail on the Join ISNIM page.

Personal Information

Name:
(First, Middle & Last)
Degrees:
Title:
Department:
Institution:
Street Address:
Address Line 2:
City:
State or Province:
Zip or Mail Code:
Country:
Telephone:
Fax:
Email:
Scientific Focus:

Membership Categories

Remittance:
Regular Membership, 3 Years
(Includes E-Journal Access)
$400
Premium Membership, 3 Years
(Includes E-Journal Access & Paper Copy)
$595
Regular Membership, 1 Year
(Includes E-Journal Access)
$150
Premium Membership, 1 Year
(Includes E-Journal Access & Paper Copy)
$222
Membership only, 1 Year
(No Journal Access)
$100
Retiree Membership, 1 Year
(Options: E-Journal: Add $50.00; E-Journal & Paper Copy: Add $72)
$50
Student/Post Doc Membership, 1 Year
(Options: E-Journal: Add $50.00; E-Journal & Paper Copy: Add $72)
$50
Sponsoring Membership for commercial firms, 1 Year
(see Join ISNIM for more information)
$2000+

Billing Information

Payment Method:


If paying by check, make the check in U.S. dollars payable to "ISNIM" and send to the Executive Director.

If you print this form and are paying by Credit Card, complete the following:
Credit Card Type:
Name on Credit Card:
Credit Card Number:
Expiration Date (MM/YY):
Total Amount Charged: $

Signature

Electronic Signature: If you are submitting this form electronically, please provide an electronic signature by typing your name in the box below.

Print Signature: If you are printing this form, please sign and date the form below.
Signature: _____________________________________________    Date: ________________


     -OR-     



If Paying By Check:

Please mail the completed form and a check in USD made payable to "ISNIM" to:

Jeannine A. Majde-Cottrell, Ph.D.
Executive Director, ISNIM
P.O. Box 41269
Arlington, VA 22204-8269, USA