APPLICATION FORM – ISSM/APSSM MEMBERSHIP 2010
| Tanggal | : | 14 Dec 2009 |
| Sumber | : | IAUI |
| Lokasi | : | - |
  International Society for Sexual Medicine
Asia Pacific Society of Sexual Medicine APPLICATION FORM – ISSM/APSSM MEMBERSHIP 2010 ………………………………………………………………… ……………………………...Prof./Dr./Mr./Mrs. Family Name First Name + Initials (please circle) I would like to receive mail to my Home-or Institute address (please circle) | Institution Address | Home Address | | Institution | ………………………………………………. | | | | Department | ………………………………………………. | | | | Street | ………………………………………………. | Street | ………………………………………………. | | City | ………………………………………………. | City | ………………………………………………. | | Postal Code | ………………………………………………. | Postal Code | ………………………………………………. | | Country | ………………………………………………. | Country | ………………………………………………. | | Telephone | ………………………………………………. | Telephone | ………………………………………………. | | Fax | ………………………………………………. | Fax | ………………………………………………. | | Email | ………………………………………………. | Email | ………………………………………………. | I am : □ UROLOGIST □ OB/GYN □ ANDROLOGIST □ PSYCHIATRIST □ BASIC RESEARCHER □ 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 brief one-page CV Your application will be reviewed by the board of the ISSM or APSSM Return this form by FAX or MAIL to : APSSM Secretariat Urology, Building B, 3rd Floor, Pusan National University Hospital 1-10, Ami-Dong, Seo-Gu, Busan, 602-739, Korea FAX: +82-51-247-5443 E-mail : bperl@hanmail.net pnc@pusan.ac.kr Website : www.apssm.org
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