Dear TAA Secretariat,
Please in future, don’t send any individual remittance as the bank
charges per transaction is USD25.00.Therefore we only received
USD30.00 for your membership payment on behalf of Dr Wai–Yan Wong.
APSSM do not have the budget to subside huge exchange losses and
bank charges. For individual payment we asked members to pay
directly to ISSM and fax/ email us the receipt from ISSM to be
included as APSSM member. I hope you understand our situation.
Attached please find a copy of the authorization to debit of credit
card for ISSM.
Thank you & kind regards,
Hui Meng TAN, FRCS(Edin), FRCPS(Glasg).
Consultant Urologist
Adjunct Professor, Faculty of Medicine, University of Malaya
Secretary General, Asia Pacific Society for Sexual Medicine (APSSM)
and
Asia Pacific Society for Study of the Aging Male (APSSAM)
1, SS12/1A, Subang Jaya 47500 Petaling Jaya, Selangor
MALAYSIA.
Tel: 603 - 5630 6777
Fax: 603 - 5630 6571
Email: perandro@streamyx.com
I would like to
receive mail to my Home- or Institute address (please
circle)
Institution Address
Home Address
Institution
Department
Street
City
Postal Code
Country
Telephone
Fax
Email
Street
City
Postal Code
Country
Telephone
Fax
Email
I am:
□ UROLOGIST □ OB/GYN ANDROLOGIST □ PSYCHIATRIST
□ RADIOLOGIST □ OTHER:………………………………………………
Percentage of professional activity devoted to sexuality and
impotence research ………………………………………%
Names and email- addresses of 2 (two) members of ISSM endorsing
your moral and professional standard
1. …………………………………………………
2. …………………………………………………
Professional degree:
Main publications:
Please attach a copy of your CV
Your application will be reviewed by the board of the ISSM
The 2007 membership includes a subscription to the Journal of
Sexual Medicine.
PAYMENT: Please tick:
Conversion USD / EUR: based on daily exchange rates.
□ Full Membership 2007
EURO 85,00
□ Trainee Membership 2007
EURO 40,00 (provide a letter of verification from your professor
or mentor)
□ Voluntary donation Adrian Zorgniotti Fund EURO ……… (minimum:
EURO 50,00).
CARD HOLDER’S INFORMATION
Name Cardholder:
City:
Country:
I hereby authorise the ISSM Executive Office to debit my
creditcard for the Grand Total amount indicated above.
Credit Card:□ Visa □ Eurocard / MasterCard □ American
Express
Card Number:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Expiry Date:
Validation Code (CVC) VISA
and Eurocard/Mastercard:
last 3 digits on signature strip (reverse side of the
card).
□ Payment by wire-transfer for total amount of EUR
…………………………
into bankaccount number
40.43.97.077 with ABN-AMRO Bank, Zeist,
The Netherlands. Please indicate “ISSM”.
Swift code (BIC): ABNANL2A
IBAN: NL04ABNA0404397077