APSR Membership Application

Step 1 - enter your details below to generate an Application Form
Step 2 - print the Application Form and sign it
Step 3 - post or fax the Application Form to the APSR Secretariat

* Mandatory input

Title(Prof.. Dr., etc)
*Family name
*Given name(s)
Accreditation(PhD., M.D., etc)
Date of birth (dd mm yyyy)
Gender(M / F)

*Contact address

line 1
line 2
line 3
City
State
Post Code
Country

*Email
*Re-type email

Telephone no.(including country)
Fax no. and city codes)

Medical Education

Institute name and location
Degrees
Date received (dd mm yyyy)

Institute name and location
Degrees
Date received (dd mm yyyy)

Institute name and location
Degrees
Date received (dd mm yyyy)

Licensure

Institute name and location
Date received (dd mm yyyy)

ATS or ERS members

Members of the American Thoracic Society or the European Respiratory Society, automatically qualify for a 15% reduction in APSR Membership dues.

ATS members

My ATS membership number is:
-- or --

I have applied to join the ATS and am awaiting my membership number. I applied on: (dd mm yyyy)

ERS members

My ERS membership number is:
-- or --

I have applied to join the ERS and am awaiting my membership number. I applied on: (dd mm yyyy)