IPTA NEW MEMBER APPLICATION

*Required Fields

*First Name:
*Last Name:
Degree(s):
*Institution:
*Institution Address:
Institution Address Line 2:
*City:
State/Province:
Zip/Postal Code:
*Country:
*Telephone:
Fax:
*E-mail:

---

DEMOGRAPHIC INFORMATION

Date of Birth:
Gender:	Male Female
Primary Specialty/ Research Interest: (Check one)	A. Bone Marrow B. Cardiology C. Cardiopulmonology D. Critical Care E. Endocrinology/Diabetes F. Gastroenterology G. Hepatology H. Immunology I. Infectious Disease J. Internal Medicine K. Nephrology L. Pancreas & Pancreas Research M. Pathology N. Pulmonology   O. Surgery   1. Heart 2. Liver 3. Lung 4. Pancreas 5. Renal P . Other
Affiliation: (Check one)	A. Industry B. Government Agency C. Private Practice D. Research Foundation E. Medical School/University F. Military G. Other:
Practice Type:	A. Research B. Clinical
Check the box that best describes you:	A. Physician B. Scientist C. Surgeon D. Nurse E. Lab Technician F. Organ Procurement Personnel G. Professional Association Personnel H. Industry / Marketing I. Trainee J. Pharmacist K. Transplant Coordinator L. Other:
Please tell us how you heard about the International Pediatric Transplant Association.

PAYMENT INFORMATION (choose one)

Member Classification and Dues:
	Regular Member - 1 year - $195.00
	Regular Member - 2 years - $350.00
	Regular Member - Developing Country (see below) - 1 year - $50.00
	Regular Member - Developing Country (see below) - 2 years - $90.00
	Allied Professional Member (nurses, coordinators, etc.) - 1 year - $100.00
	Allied Professional Member - 2 years - $180.00
	Allied Professional Member - Developing Country (see below)- 1 year - $50.00
	Allied Professional Member - Developing Country (see below)- 2 years - $90.00
	Emeritus Member - must turn 70 years of age in the year prior to the membership year AND submit a written letter (e-mail accepted) requesting the status (NOTE: This membership does not include a print subscription to the journal) – FREE
	Emeritus Member - with optional subscription to Pediatric Transplantation - $100.00
	**Trainee (residents, fellows) - 1 year - $100.00
	**Trainee - 2 years - $180.00
	**Trainee - Developing Country (see below) - 1 year - $50.00
	**Trainee - Developing Country (see below) - 2 years - $90.00
	If you are located in a developing country please select your country from the list...
	Developing Countries Afghanistan Angola Armenia Bangladesh Benin Bhutan Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Comoros Congo,Dem.Rep. Congo,Rep. Côte d'Ivoire Djibouti Eritrea Ethiopia Gambia,The Georgia Ghana Guinea Guinea-Bissau Guyana Haiti Honduras India Kenya Kiribati Korea,Dem.Rep. Kyrgyz Republic Lao PDR Lesotho Liberia Madagascar Malawi Maldives Mali Mauritania Moldova Mongolia Mozambique Myanmar Nepal Nicaragua Niger Nigeria Pakistan Papua New Guinea Rwanda Samoa SãoTomé and Principe Senegal Sierra Leone Solomon Islands Somalia Sri Lanka Sudan Tajikistan Tanzania Timor-Leste Togo Tonga Uganda Uzbekistan Vanuatu Vietnam Yemen,Rep. Zambia Zimbabwe
**All trainees joining the association must include their training program directors name.
	**Training Program Director's Name:

---

CREDIT CARD INFORMATION

Credit Card Type	Visa MasterCard Amex
Credit Card Number
Expiration Date
Card Holder's Name