GRS
The Growth Hormone Research Society
Secretariat: Medical Department MEA, Aarhus University Hospital
Nørrebrogade 44, DK-8000 Aarhus C, Denmark
Tel. +45 89492012  Fax. +45 86125013
email: grs@ki.au.dk
webpage: www.ghresearchsociety.org

2012-2013 MEMBERSHIP PAYMENT FORM

MEMBERSHIP NUMBER:		
FAMILY NAME:		
FIRST NAME:		
ADDRESS FOR CORRESPONDENCE:	
STREET:		
CITY,    POSTAL CODE:		
COUNTRY:		
TELEPHONE NUMBER:		
FAX NUMBER:		
E-MAIL: (legible please)		

MEMBERSHIP FEE 2012+2013	total	        USD 80	

Membership includes free subscription to the official journal of the Society and ensures reduced registration fee for the joint GRS/IGF Society meetings (further information on the webpage)

Payment options include bank transfer, check or credit card.

Please CLEARLY INDICATE YOUR NAME on a bank transfer to the GRS:
PLEASE NOTE
**THAT ALL BANK CHARGES ARE THE RESPONSIBILITY OF THE SENDER**

GRS Account Number:	
The 6th International Congress of the GRS and IGF Societies, Munich, Germany, October 17-20, 2012
www.grs-igf2012.org

Growth Hormone & IGF Research
Official journal of the Growth Hormone Research Society
and the IGF Society.
	
DANSKE BANK
2-12, Holmens Kanal
DK-1092 Copenhagen K, Denmark
Telex 27000 - S.W.I.F.T. DABADKKK
IBAN DK53 3000 3630 4053 27
For the credit of our account No.
3627 3630405327
Please state account number in full		

I authorize the GRS to charge the above-mentioned amount to my CREDIT CARD.
	Master Card			Visa		Credit Card No:	
	Eurocard			JCB		Expiry Date:	

Date:	SIGNATURE:	

Please return this form (with a copy of the bank transfer or check) to the GRS secretariat (pdf-version is acceptable).	

GRS

Secretariat: Medical Department M, Aarhus University Hospital
Nørrebrogade 44, DK-8000 Aarhus C, Denmark
Tel. +45 89492012, Fax. +45 86125013
email: grs@ki.au.dk

APPLICATION FOR MEMBERSHIP

	Thank you for your recent inquiry about becoming a member of the Growth Hormone Research Society. The payment form for membership is enclosed. Payment includes 2 years of membership.
	As the Society is based on individual memberships only, we would like to know something about your interest in the field of growth hormone and growth hormone related substances. 
	Please fill in the information requested and arrange for payment of the appropriate amount or provide us with details of one of the listed credit cards and return this form to the Secretariat. 
	We look forward to seeing you at our next meeting, to be held October 17-20, 2012 in Munich, Germany.

Please PRINT OR TYPE

NAME AND ADDRESS:

	

QUALIFICATIONS AND/OR ACADEMIC DEGREES:

	

PRESENT PROFESSIONAL POSITION, PLACE OF WORK:

	

I wish to become an Active Member of the Association, and shall abide by its Statutes.

DATE:	SIGNATURE:	

Please attach a brief (1 page) CURRICULUM VITAE.