New Membership / Renewal Application Form

for COMPANY membership

Name of the Company:

MailingAddress:

City,State,Zip:

Country:

Phone: Fax:

E-mail: Website:

COMPANY MEMBERSHIP PAYMENT

Membership Category Fee
[ ] Number of members 35 € / year/ person
A full list of the members with addresses and
! IMPORTANT e-mail addresses must be enclosed.

We wish to be accepted as a member of the European Society of Preventive, Regenerative and Anti-Aging Medicine
and agree to abide by its By Laws and Code of Ethics:

Signature of the Society Representative: ........................................................................... Date: .............................................

Please Select a Voluntary Contribution Level (optional) [ ] Euro € 50 [ ] Euro € 100 [ ] Euro € 150 [ ](Other)............................
Payment in the amount of Euro .....................................................................is enclosed (membership dues + contribution)

PAYMENT INFORMATION
Your membership will not be processed without full payment payable to the following account.

Account holder:

IBAN:DE92 8005 3572 0030 0181 37

BIC:NOLADE21DES
Payments by credit card or personal check cannot be accepted.
REMIT COMPLETED FORM TO:
_________________________ Privileges of ESAAM Society membership for its members:
?Reduced registration fee in the European Congresses of
ESAAM Preventive, Regenerative and Anti-Aging Medicine (ECOPRAM)
c/o Dessau Medical Center ?Special subscription price for our official journal Rejuvenation
Prof. Dr. Christos C. Zouboulis Research (impact factor 5.008) of 89 $ per year for online access (which
Auenweg 38 will include the entire journal archive) and 129 $ if they wish to receive
06847 Dessau the print journal.
Germany ? The biannual ESAAM bulletin (online access).
? A Society membership diploma and special annotation at the
Attn: MembershipDepartment ESAAM website
? A copy of the Society membership diploma to each of its
Tracking Group#:_____________________ members and a membership card – as members of a Society member