membership
INTERNATIONAL SOCIETY OF CARDIOVASCULAR ULTRASOUND
Address for Correspondence:
Navin C. Nanda, M.D.
4240 Kennesaw Drive
Birmingham, AL 35213 USA
Phone : 205 807 0731
e-mail: iscuorg@yahoo.com
ISCU Membership Form
Last__________________________First Name____________Middle Initial____Degree(s)___________________
Title and Affiliation ____________________________________________________________________________
IF PAYING BY CREDIT CARD, PLEASE USE THE BILLING ADDRESS FOR THE CREDIT CARD
Street Address_______________________________________________________________________________
Additional Address ____________________________________________________________________________
City___________________________State_________Zip/Postal Code___________Country__________________
Office Phone: Country code_________City code____________Number_____________________________
Office Fax: Country code___________City code ___________Number______________________________
E‑mail (print):_____________________________________@____________________________________
[ ] Physician [ ] Technologist [ ] Other__________________________________
[ ] Regular member dues (US$50.00 per year cash or check; US$55.00 per year credit card)
[ ] Fellowship dues – membership payable for 3 year only
______US$110.00 for physicians (1 year)
______US$70.00 for non-physicians (1 year)
______US$255.00 for physicians (3 years)
______US$155.00 for non-physicians (3 years)
[ ] Check/money order enclosed (Check made payable to: ISCU; drawn on a USA Bank in USA dollars)
[ ] Charge my credit card as indicated below
[ ] VISA [ ] MasterCard [ ] Discover
Credit Card Number _____________________________________________________________
Credit Card Expiration Date__________________ CVV #________________(3 digit number listed on back of credit card)
Name Printed on Card___________________________________________________________________
Signature_____________________________________________________________________________
The completed form must be accompanied by a check/money order for dues in USA dollars, drawn on a USA bank only) payable to ISCU, or credit card information filled out and signed.
Send to: ISCU, Dr. Ming C. Hsiung, Treasurer 4240 Kennesaw Drive, Birmingham, AL 35213 United States of America
Phone: 205 807 0731 E‑mail: iscuorg@yahoo.com; Web site: http://www.iscu.org
If paying by credit card, a scanned copy of this form with all information can be emailed to iscuorg@yahoo.com.
