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Membership Application The American Association for Medical Chronobiology and Chronotherapeutics (Please Type or Print Clearly) Name: ____________________________________________________________________________ Title: _____________________________________________________________________________ Office Address: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ City: _______________ State: _______________ Country: _________________ Zip: __________ Home Address: ________________________________________________________________ ________________________________________________________________ City: _______________ State: _______________ Country: _________________ Zip: __________ Phone/FAX/Email Numbers: Telephone No: (work) ______________________ Telephone No: (home) ______________________ Fax: ____________________________ Email Address: _________________________________ Interests: Please indicate areas of interests or specialties ______________________________________ ______________________________________ ______________________________________ ______________________________________ I wish to apply for: _____ Regular Membership - $90/yr (Annual Dues and Chronobiology
International published by
_____ Regular Membership - $15/yr (Annual Dues for paid
members of the International Society of
_____ Student (Undergraduate, Graduate, Postdoctoral,
Resident, etc.) Membership - $65/yr (Annual _______________________________ __________ _______________________________________ Signature of Applicant Date Student Members - Signature of Teacher o Check in U.S. Dollars payable to Marcel Dekker, Inc. Reminder: Banks outside of U.S. must havea corresponding bank in U.S. and checks must be made in U.S. dollars o Credit Card: ___ American Express, ___ VISA, ___ Mastercard/Eurocard, ___ Diners ClubCredit Card Number: ________________________________ Expiration Date: ____________ Signature of Cardholder: _____________________________________ Mail Completed Form to: Taylor & Francis, Inc. Attn: Andrew Moyer, Managing Editor 325 Chestnut Street Philadelphia, PA 19106-9118 USA Fax: 215-625-8914
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