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

	I want to become a member of the International Association for Cannabis as Medicine
	I want to pay Euro/US dollars 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
Rueckertstrasse 4
53819 Neunkirchen
Germany

Fax: +49-2247-9159223

Payment information:
Please make your payment to IACM (by check in Euro or US dollars) and mail to: IACM, Rueckertstrasse 4, D-53819 Neunkirchen, Germany.

You may remit credit card payments by faxing credit information to +49-2247-9159223. 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), Account Number 440099504.