MESSM/ISSM Membership APPLICATION

This form can be used to apply for MESSM/ISSM membership. Your membership application will be reviewed within 7 working days and, if approved, you will become a member for 2016. At the end of each calender year, a tacit renewal of your membership is applicable, for which you will be invoiced in November of the running year.

All data submitted on this form will be processed on a Secure Server (SSL), which is owned and maintained by the company managing the ISSM Secretariat "Status Plus B.V." in The Netherlands. For more information please contact us by phone +31-75-6476372 or e-mail secretariat@issm.info.

On-line Membership Application Form - Step 1 of 3

 
Gender:  M   F    
Title (Prof., Dr., etc.):   
First name:   
Last name:   
Suffix (MD, PhD, etc.):   
Institution/organization:   
Department:   
Function:   
Cell phone:   
Skype name:   
Personal website/profile:   
E-mail 1 (main):   
E-mail 2 (alternative):   
 
Prefered mailing address:  work    home   
 
Work address:   
   
City:   
Province/State:   
Zip code:   
Country:  
Work phone:   
Extension:   
Work fax:   
Corporate website:   
 
Home address:   
   
City:   
Province/State:   
Zip code:   
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Home phone:   
  

Additional professional information


Percentage of professional activity devoted to sexual medicine: %
Professional degree:
Medical specialty:
Main publications:
On-line CV (link): http://

The ISSM office may request you to provide additional professional information by e-mail if you can/do not provide the information above.
 


MESSM/ISSM Membership 2016


MESSM/ISSM FULL Membership is valid for one full calender year (January 1st to December 31st, 2016) and includes a subscription to the Journal of Sexual Medicine (monthly) and Sexual Medicine Reviews (quarterly). Further benefits to members are discounted author publication fees for publishing in ISSM's Open Access journal 'Sexual Medicine', registration fees for all MESSM/ISSM Meetings and Symposia and access to an active website and intranet for discussion among MESSM/ISSM members of vexing problems and cases (see ISSM website).

MESSM/ISSM FULL membership fees are based on and will be charged in EURO's (click on the rates below for a real time conversion into USD). To determine applicable membership fees, the MESSM/ISSM applies the World Bank classification based on the gross national income (GNI) per capita, resulting in 3 different membership categories, which are: A - high income countries, B - middle income countries, and C - low income countries. For a full list see www.issm.info. When applying/renewing the applicable membership category and membership fee as described below will be automatically applied and calculated.

New in 2016: ISSM waives your membership fee if you are a Resident/Student enrolled in a school of medicine, psychology nursing or other health care field or enrolled in a graduate training program or residency program in a field related to practice and/or research in sexual medicine (eg Urology, Gynecoglogy, etc.) and want to apply for MESSM/ISSM RESIDENT/STUDENT Membership, which excludes voting rights and subscriptions to the Journal of Sexual Medicine and Sexual Medicine Reviews but includes all other benefits mentioned above.


Membership Category Membership Fee
MESSM/ISSM Full Membership 2016 - Cat. A (high income countries) EUR   140
MESSM/ISSM Full Membership 2016 - Cat. B (middle income countries) EUR   100
MESSM/ISSM Full Membership 2016 - Cat. C (low income countries) EUR   40
MESSM/ISSM Resident/Student Membership 2016 (***) EUR   0
(***) To qualify for resident/student membership, written proof of your status as a student is required when applying (for example, a copy of your student ID or a letter declaring your status, dated and signed on your institution's letterhead/stationary). Upon submitting your application, please also send a scan of the supporting documentation by e-mail to secretariat@issm.info. NOTE: Your resident/student membership application is not considered complete without supporting documentation and will not be processed until such proof is duly received.

I want to apply for Resident/Student Membership: Yes   No    
 

Donation to the Zorgniotti Foundation


The Zorgniotti Foundation was established in 1994 after Adrian Zorgniotti, founder and first President of the International Society for Impotence Research (ISIR) that is currently known as the International Society for Sexual Medicine. The mission of the Fund is to finance scholarships and grants for young researchers in the field of sexual dysfunction through its relationship with donors. The financial resources of the Foundation will be distributed for basic and clinical research in the field of sexual medicine, for training of professionals in the field of sexual medicine and for public education. The Zorgniotti Foundation is organized under the auspices of the ISSM Grants and Prizes committee and the ISSM Board of Directors. The ISSM would like to thank you in advance for your contribution to this important foundation.

Donation to Zorgniotti Foundation:  EUR  (Donation in EURO's, Click here for exchange rates)
 

Payment


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