ASIA PACIFIC
CONTINENCE ADVISORY BOARD
Prof Peter H C Lim
Chairman
c/o Society for Continence
(Singapore)
Department of Urology
Changi General Hospital
2 Simei Street 3
Singapore 529889
Tel/Fax: (065) 787 0337
Application
for Individual/Corporate Membership of the
Asia Pacific
Continence Advisory Board
Name: ___________________________________ Prof/Dr/Mr/Ms: _______________________________
Given Name/First Name: _________________________________________ Initial: __________________
Profession/Specialty: ______________________________ (Urologist, Gynaecologist, Geriatrician, Colorectal
Surgeon, proctologist, Physiotherapist, Nurse)
Institution/Office Address OR Home Address:
______________________________________________________________________________________
______________________________________________________________________________________
City/State: _______________________________ Postal Code: __________________________________
Country: ___________________________ E-mail Address: _____________________________________
Phone: _____________________________________Fax: ____________________________________
(Country Code + Area Code + Number)
…………………………………………………………………………………………………………………
SUBSCRIPTION
The fee payable for different membership categories are shown below:
INDIVIDUAL MEMBER
US $100/- entrance fee ; US $10/- annual subscription
CORPORATE MEMBER
US $350/- entrance fee; US $200/- annual subscription
Please note
1. Individual and Life Memberships are opened to Medical professionals.
2. Corporate Membership is opened to all commercial bodies, firms, government departments, clubs or any organisation interested in supporting the Society in furthering its aims.
Crossed cheque/Banker's Draft should be made payable for "Society for Continence (Singapore)" accompanied with the application form and mail to the above Secretarial address.
Cheque/Banker's Draft No. ___________________________ Date: _______________________________
Approved by: _____________________ _________________________ _______________________
Chairman Secretary-General Full Member (As sponsor)