APPLICATION FOR ESSM MEMBERSHIP (+ PAYMENT 2012)

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Mr/Ms: *

MrMs

Title:

First name: *

Last name: *

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HomeWork

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Specialities

1.

2.

Membership type: *

ESSM MemberESSM + ISSM Member

 

Herewith confirms the payment of EUR 50,00 for the ESSM membership cost for the year 2012:
Herewith confirms the payment of EUR 120,00 for the ESSM and ISSM membership cost for the year 2012:

 

Membership category:

Full MemberAssociated Member

MEMBERSHIP GOES FROM JANUARY TO DECEMBER

Special interests / expertise in Sexual Medicine (For new members only!)

1.

2.

Preferred way of payment: *

Bank Transfer
Cheque headed to AISC & MGR srl / ESSM
Credit card

Bank transfer to AIM Congress srl / ESSM
Bank: Banca Popolare di Milano - AG.24, Milano, Italy
Account No.: 000000024845
Bank Codes:
CIN K
ABI 05584
CAB 01624
IBAN: IT81K0558401624000000024845
BIC: BPMIITM1024

Please clearly state in the reason of payment: ESSM fee + Family name
Please send a copy of the bank transfer by fax (+39 027 0048 577) or email (admin@essm.org).

Credit Card:

VISAAMERICAN EXPRESSMASTER CARDEUROCARD

Card number:

Expiration date:

CVN:

Card holder:

Data protection

Privacy and treatment of personal data
In order to process your membership of the European Society for Sexual Medicine (ESSM) we will store your details in an electronic database. This information will be used to process your application only and will not be used for any other communications. The information will not be sold, lent or otherwise divulged to third parties, other than where it is necessary to process your application.
Should your membership application be successful, your details will be stored permanently in a database and you will have an account set-up within www.essm.org where you will be able to manage your personal details and renew your membership annually. These details will not be sold, lent or otherwise divulged to third parties other than to manage your membership, send you relevant information about ESSM events and services and provide any services you request from time to time. We may use your personal details to send you communications from third parties without divulging your details to them.
If you choose the combined membership of ESSM/ISSM we will then pass your details to ISSM allowing them to register your membership and send you the Journal of Sexual Medicine.
Other than the ISSM, your personal information will never be sent outside the EU other than to countries where this is allowed under EU laws.
Should you have any concerns about the use of your personal details, please email admin@essm.org or write to AIM Congress Srl - AIM Group - Via Ripamonti 129, 20141 Milano - C.a. Ms. Lavinia Ricci For your consent on data processing and communication as described in the above report:

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