Membership Application Form

We would like you to become a member of the International Association for Cannabinoid Medicines. Please choose between regular member (medical profession) and associate member (patients, supporters).

If you have a credit card (Mastercard, VISA CARD) you may use the online form. Otherwise please use the form below and send or fax it to the IACM office.


Regular member (physician, pharmacist, etc.) 60 Euro
Regular member (medical institution) 120 Euro
Associate member (working) 60 Euro
Associate member (not working, student) 30 Euro

I want to become a member of the International Association for Cannabinoid Medicines
  I want to pay Euro as membership fee (see above).
I want to be listed in the society directory.
I do not want to be listed in the society directory.

Last name, first name  Degree 
Adress
 
 
ZIP Code/City
Country
Phone  Fax 
E-Mail
Date  Signature: _________________________

Please print out and send or fax to:
IACM
Am Mildenweg 6
59602 Rüthen
Germany
Fax: +49-2952-902651

Payment information:
Please make your payment to IACM (by check in Euro) and mail to: IACM, Am Mildenweg 6, D-59602 Ruethen, Germany.

You may remit credit card payments by faxing credit information to +49-02952-902651. It will safely and directly come to our IACM office.

Credit Card Information:
Visa MasterCard
Exp. Date:
Card number: _____________________________
Signature: _____________________________

You may also transfer your membership fee to IACM, Postbank Koeln (Swift-Code: PBNKDEFF), IBAN: DE32370100500440099504, Account Number 440099504.

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