subject_line
ISPCOP Membership Application/Renewal
First Name
*
Family Name
*
Degree
*
Email Address
*
Institution/Hospital
*
Department
*
Preferred Address
*
Address Line 2
City
*
State/Province/Region
*
Zip/Postal Code
*
Country
*
Phone Number (country code + area code + number)
*
I authorize ISPCOP to list my name, hospital, city, and country on the website.
*
Yes
No
I authorize ISPCOP to list my email address on the website.
*
Yes
No
I am a member of ASA
*
Yes
No
I am also a member of:
*
ESCOP
IFSO
SOBA
N/A
Other (if more than one, please separate with commas):
Other (if more than one, please separate with commas):
Membership Categories
Are you a current member?
*
Yes, I wish to renew my membership (2023)
No, I am a new applicant (2023)
Please select a membership category below.
*
Active (1-year membership) ($50 US per year)
Active (3-year membership) ($135 US)
Affiliate (1-year membership) ($50 US per year)
Fellow/Resident (1-year membership) (Free)
Medical Student (1-year membership) (Free)
Donate to ISPCOP
Would you like to donate to ISPCOP? Please choose an option below. We thank you for supporting our organization.
$10.00
$25.00
$50.00
$100.00
$250.00
$500.00
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