Members













Application form: ASSOCIATE MEMBERSHIP (this applies to individual physicians)
Please complete this application IN FULL, in English, French, or Spanish.
Surname
First Name
Title
Medical Speciality
Organization
Work Address
P.O. Box
ZIP/City
Country
Home Address
P.O. Box
ZIP/City
Country
Daytime telephone
Fax
E-mail
I HEREBY APPLY FOR INDIVIDUAL ASSOCIATE MEMBERSHIP OF THE WORLD MEDICAL ASSOCIATION (Please click on the appropriate box)
Country Group: * A B C D
Annual membership 15 € 34 € 57 € 75 €
Five-Year Membership 60 € 135 € 225 € 300 €
* New Dues scheme effective from January 1st 2009.
Valid for the new members, and renewal membership

1) By cheque payable to

The World Medical Association
C.I.B. Building  “Le J. Keynes”
General Secretariat, B.P.  63, 01212 Ferney-Voltaire Cedex, France

2) Or for Bank transfer

Name of the Bank:   SOCIETE  GENERALE
                                    4, avenue Voltaire
                                    01210  Ferney-Voltaire, France

National bank transfer (in France)
Code Banque           Code guichet          N° de compte              Clé rib
30003                          00109                      00037260094              56

International bank transfer  (IBAN)                             BIC
FR76 30003 00109 00037260094 56 (Euros)           SOGEFRPP
FR76 30003 00109 00077290042 92 (Dollar Us)

We regret that we cannot accept credit card payment for membership dues.
Membership includes a 24-hour accident death insurance; a privilege for WMA Associate Members.
The insurance will pay US$ 10,000 for death due to any accident PLUS US$ 10,000 for death due to accident in a commercial airline for a total of US$ 20,000.
Please indicate the Beneficiary Name for the insurance
Beneficiary Address

Send all mail to

 Office address
Home address
Language preference for communications English
French
Spanish
Validation code Insert the code (case sensitive):
N.B.: The WMA, Inc. is a tax-exempt organization. Membership dues are tax deductible.

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