For more information please visit
PAYMENT OF THE ESSM MEMBERSHIP FEE 2014
To be sent back to:
Membership goes from January to December
ESSM secretariat – c / o AIM Congress
Phone: +39 02
–
56601 354
Via Ripamonti 129 – 20141 Milano, Italy
Fax. +39 02
–
70048 577
❑
New Member
email:
❑
Member since: ______________________
T
itle:
Name:
Surname:
Date of Birth:
Nationality:
Position held:
Institution:
Postal address:
❑
home
❑
work
City:
Zip code:
Country:
Telephone:
Fax:
Email:
First Specialty:
Second Specialty:
Membership category:
Membership type:
❑
Full Member
❑
Simple Essm
EUR 50,00
❑
Associate Member
❑
Combined Essm + Issm EUR 130,00
Special interests / expertise in Sexual Medicine – for new members only
1.
2.
Scientific work (two most important – peer reviewed – publications) – for new members only
1.
2.
❑
Herewith confirms the payment of EUR 50,00 for the
ESSM membership
cost for the year 2014 by:
❑
Herewith confirms the payment of EUR 25,00 for the
ESSM membership FOR RESIDENTS IN TRAINING
* cost for the year 2014
❑
Herewith confirms the payment of EUR 130,00 for the
ESSM and ISSM membership
cost for the year 2014
* A letter of the Chairman of the Department is necessary
❑
Bank transfer to AIM Congress srl
Bank:
Banca Popolare di Milano – Ag. 24 – Milano, Italy
Account N.:
000000024845
Bank codes:
CIN
K
ABI
05584
CAB
01624
IBAN
IT81K0558401624000000024845
SWIFT /BIC BPMIITM1024
Please clearly state in the reason of payment: ESSM fee + name and surname
❑
Credit Card:
❑
Visa
❑
American Express
❑
Master Card
❑
Eurocard
Credit Card number:
Expiration date:
CVC Number
Holder
Holder’s Signature
Privacy and treatment of personal data
In order to process your membership of the European Society for Sexual Medicine (ESSM) we will store your details in an electronic database. This
information will be used to process your application only and will not be used for any other communications. The information will not be sold, lent or
otherwise divulged to third parties, other than where it is necessary to process your application.
Should your membership application be successful, your details will be stored permanently in a database and you will have an account set-up within
where you will be able to manage your personal details and renew your membership annually. These details will not be sold, lent or otherwise
divulged to third parties other than to manage your membership, send you relevant information about ESSM events and services and provide any services
you request from time to time. We may use your personal details to send you communications from third parties without divulging your details to them.
If you choose the combined membership of ESSM/ ISSM we will then pass your details to ISSM allowing them to register your membership and send
you the Journal of Sexual Medicine. Other than the ISSM, your personal information will never be sent outside the EU other than to countries where this
is allowed under EU laws.
Should you have any concerns about the use of your personal details, please email
or write to
AIM Congress Srl – AIM Group – Via Ripamonti 129, 20141 Milano – C.a. Ms. Lavinia Ricci
For your consent on data processing and communication as described in the above report:
Date
Signature
