Application Form

June 12, 2009 by imlasadmin

Last name: *

Firstname: *

Title:

Birth date: *

Address: *

City:

Postal code:

Country: *

Telephone: *

Fax:

E-mail: *

Web page:

Education:

Laser activity:

Membership sought: *

My address can be made available ...:

Payment:

By Cheque

By International Bank Transfer

By Credit Card (Mastercard/VISA/Maestro)

By Cheque
Please send made payable to 'IMLAS' to the IMLAS Office (Office Block 1, Southlink Business Park, Hamilton Street, Oldham Lancs, U.K, OL4 1DE )

By International Bank Transfer
IMLAS - Account No. 01472648, Royal Bank of Scotland, Bolton Central Branch 46-48 Deansgate, Bolton, Lancashire BL1 lBH. England

By Credit Card (Mastercard/VISA/Maestro) Please fax to +44 (0)161 628 1834
We require: Name on Card, Card Number, Card Security Code (3 digit number printed on the signature strip on back of the card), Expiry Date, and Amount Due

Confirmation:

Please confirm your understanding of this statement by ticking this box

I recognise that my application for membership of the International Musculoskeletal Laser Society “IMLAS” is subject to the Society’s Articles of Incorporation, Bylaws and any other rules and regulations that the Society may adopt. I accept that IMLAS membership is a privilege, not a right. I agree to make no claim or complaint, directly or indirectly, against the Society, its members, directors, officers or agents for any damage or liability by reason of any action that any of them may take in connection with this application.

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Application Form

June 12, 2009 by imlasadmin

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