IALMH Membership Registration - Fax or Mail

Kindly complete, print out and send by fax or mail,the Credit Card Authorization Formprovided below.

Please be sure to include your e-mail address and fax number.

Credit Card Authorization Form

[FrontPage Save Results Component]

Title: First Name: Family Name:

Institution:
Complete Mailing Address:

Telephone (with country and city codes):
FAX (with country and city codes):

E-Mail address:

Name on Card
Card No.
Expiry Date      /              VISA         Mastercard (19 digits)
                         mm /    yy

I wish to become a Member of the Academy:

Signature______________________date(DD/MM/YY)_____________

PLEASE RETURN BY FAX OR MAIL TO:
International Academy of Law and Mental Health
c/o Chaire de psychiatrie légale et d`éthique biomédicale Philippe Pinel
Faculté de médecine, Université de Montréal
C.P. 6128, Succ. Centre-Ville
Montréal, QC H3C 3J7 CANADA

Tel: (1) 514-343-5938

Fax: (1) 514-343-2452

E-mail: admin@ialmh.org

Return to Main Page