SOUTH ASIAN SOCIETY FOR SEXUAL MEDICINE SASSM Membership Terms & Condition: MEMBERSHIP: The following categories of persons shall be eligible for admission as members of the society namely; Urologists, Endocrinologist, Rheumatologist, Orthopaedicians, Cardiologist, Surgeons, Psychiatrist, Medical Practitioners, Gynaecologist, Radiologists, Oncologist, General Physician, Internal Medicine Specialist, Scientist, Social Workers, Educators, Community workers, journalists & all those persons as are interested in teaching, research & development activities of all aspects of sexual medicine. The SASSM membership opens to all health professionals living/working in the Southern and Western part of Asia. Countries that can get membership in our society: Category A Countries: Kazakhstan, Maldives, Turkmenistan Category B Countries: Bhutan, India, Pakistan, Sri Lanka, Uzbekistan Category C Countries: Afghanistan, Bangladesh, Kyrgyzstan, Nepal, Tajikistan. SASSM SECRETARIAT: Ankur, #55 (Old #422), 20th Main, 1st Block, Service Road of WOC, Next to Bhima Jewellers, Rajaji Nagar, Bengaluru, Karnataka ‐ 560 010, India Tele: +91‐80‐49043333 E‐mail: [email protected] All data submitted on this form will be processed on a Secure Server (SSL), which is owned and maintained by the company managing the SASSM Secretariat in Bangalore. For more information please contact us by phone +91‐80‐49043333 or e‐mail [email protected] / [email protected] Gender M F Title (Prof., Dr., etc.) First Name Last Name Suffix (MD, PhD, etc.) Institution/Organization Department Cell phone Landline Number E‐mail Percentage of professional activity devoted to sexual medicine specialty Professional degree Preferred mailing address Alternative mailing address SASSM Membership 2014 SASSM membership fees are based on and will be charged in Indian Rupees. To determine applicable membership fees, the ISSM applies the World Bank classification based on the gross national income (GNI) per capita, resulting in 3 different membership categories, which are: A – high income countries, B – middle income countries, and C – low income countries. For a full list see www.issm.info. When applying/renewing the applicable membership category and membership fee as described below will be automatically applied and calculated. PAYMENT DETAILS: Name of Account: South Asian Society for Sexual Medicine; A/c No: 912020060300975 ; IFS Code: UTIB0000559. Bank: Axis Bank Ltd; Branch: No.5/111, 1st Main, 1st Block, Dr.Rajkumar Road, Rajajinagar, Bangalore ‐ 560010. Payment can be by DD or by cheque or by wire transfer. SASSM account opening is in process and the funds collected in the ANKUR RITS account will be remitted to SASSM Account in due course. Details of cheque/DD no: ______________________________ Date: _______________________________________ Bank Name and Address: ______________________________ Wire transfer details: ___________________________ SASSM ONLY (NO ISSM MEMBERSHIP) FEE STRUCTURE KINDLY NOTE THIS IS ALSO AN ANNUAL MEMBERSHIP Tick Membership Category Membership Fee (INR) SASSM Full Membership–Cat. A 65 USD + ` 4,000 Countries: Kazakhstan, Maldives, Turkmenistan SASSM Full Membership 2012 – Cat. B Countries: Bhutan, India, Pakistan, Sri Lanka, Uzbekistan SASSM Full Membership 2012 – Cat. C 50 USD + ` 3,000 20 USD + ` 1,000 Countries: Afghanistan, Bangladesh, Kyrgyzstan, Nepal, Tajikistan Benefits of SASSM only membership: Valid for one year from Jan 1st ‐ Dec. 2014. It includes access to SASSM website, receiving interesting articles on Sexual Medicine and ISSM news articles through email and discounted registration to SASSM meetings. Steering committee – SASSM: Dr. Vasan S S / Dr. Rupin Shah / Dr. Narayan Reddy D SASSM SECRETARIAT: Ankur, #55 (Old #422), 20th Main, 1st Block, Service Road of WOC, Next to Bhima Jewellers, Rajaji Nagar, Bengaluru, Karnataka ‐ 560 010, India Tele: +91‐80‐49043333 E‐mail: [email protected] Website: www.sassm.in