ASIAN SOCIETY FOR FEMALE UROLOGY

Prof Peter H C Lim

President

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

Asian Society for Female Urology

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 $50/- entrance fee US $20/- annual subscription

CORPORATE MEMBER

US $150 entrance fee; US $100 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)