The Scientific Network on Female Sexual Health and Cancer

Membership Application

This form can be used to apply for membership in The Scientific Network on Female Sexual Health and Cancer. Your membership application will be reviewed by the Board and if approved, you will become a member for 2017. At the end of each calendar year, a tacit renewal of your membership is applicable, for which you will be invoiced at the end 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 Network Association Management Company "Status Plus". For more information please contact us by phone +1 (952) 683 1878 or e-mail network@statusplus.net.

On-line Membership Application Form - Step 1 of 3

 
Gender:  M   F    
First name:   *
Middle name:   
Last name:   *
Degrees (MD, PhD, etc.):   
Institution/organization:   *
Department:   
Cell phone:   
Skype name:   
Date of birth:   
Personal website/profile:   
On-line CV (link):http://
E-mail 1 (main):   *
E-mail 2 (alternative):   
 
Prefered mailing address:  office    home   *
 
Office address:   *
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City:   *
Province/State:   
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Country:   *
Work phone:   
Extension:   
Work fax:   
Corporate website:   
 
Home address:   *
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Home phone:   

The Network Membership 2017


The Network Membership is valid for one full calender year (January 1st to December 31st, 2017). More information about the different membership benefits and categories can be found on our website.

Membership Category Membership Fee
The Network 2017 Membership for Professional Clinicians, Practitioners or Researchers $   100
The Network 2017 Membership for Student/Trainees $   45
The Network 2017 Membership for Patient Advocates $   0
* To qualify for 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 network@statusplus.net or fax it to: +1 (612) 808 0491. NOTE: Your student membership application is not considered complete without supporting documentation and will not be processed until such proof is duly received.
 

Payment


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