SHOCK SOCIETY MEMBERSHIP APPLICATION
Attn: Dr. Hank Simms
TEL: (215) 456-6930 FAX: (215) 456-3529
Please Print this form

Print or Type and mail to the following:
MAIL: Albert Einstein Medical Center
Dept Surg, Klein 510, 5501 Old York Rd
Philadelphia, PA 19141
Name First Middle Last
Department
Institution
Address
City State Zip
Phone Fax  
E-mail
Highest Degree Present Position
Education & Academic Degrees
Professional Experience
Type of Membership (check one):
  
____FULL MEMBER.
Dues are $220 US dollars and includes a subscription to the journal, SHOCK. Outside North America add $45 to cover international postage for the journal.		  

____STUDENT MEMBER.
Dues are $50 US dollars without the journal, or $170 US with the journal. Outside North America add $45 to cover International postage for the journal. Application must be signed by a FULL MEMBER in good standing:
    Sponsor's Signature__________________________________Date_______

 
   
Applicant's Signature____________________________________Date_______
To pay by credit card complete information below.
___ VISA   ___ MASTERCARD ___ AMERICAN EXPRESS
Credit Card Number _____________________________________________
Expiration Date _____________________________________________
Signature _____________________________________________

 

IMPORTANT MAILING INSTRUCTIONS
* Mail original and six (6) copies of this application to the address listed on the application.
* Enclose original and six (6) copies of a brief CV showing relevant publications.
* For Student Membership: certification of status as a student or postdoc (under 2 years) required. Renewal for up to 5 years.
* A check or credit card for annual dues payable to the SHOCK SOCIETY must accompany this application.