Access to unrivalled expertise in the field of therapeutic drug monitoring and clinical toxicology
IATDMCT Business Office 4 Cataraqui Street, Suite 310 Kingston Ontario K7K 1Z7 Canada Tel: 613-531-8166 / Fax: 613-531-0626 office@iatdmct.org / www.iatdmct.org IATDMCT Membership Application Form Name surname first name title (eg. Dr.) Position: Institution: Street/Campus Address city province/state postal code/zip code country Tel Fax: Email: If Young Scientist, give date of birth (mmddyyyy) MEMBERSHIP INFORMATION Degrees ☐ MD ☐ Ph.D. ☐ Pharm.D. ☐ Technologist ☐ Industry ☐ Other Areas Of Interest ☐ Clinical Pharmacology☐ Clinical Chemistry ☐ Clinical Pharmacy ☐ Therapeutic Drug Monitoring ☐ Pharmacokinetics ☐ Drugs of Abuse ☐ Other Please check your Membership Category and record the dues payable. Go to page 2 to check the list of countries eligible for “Developing Country” status. PAYMENT: ☐ Check enclosed. Payable in US dollars to “IATDMCT” ☐ Credit card Payment ☐ Visa ☐ MasterCard ☐ American Express Card number Expiry Date Security Code 3 digit number on back of card Signature: Your credit card statement will indicate that payment was made to “Events & Management Plus Inc.” IATDMCT Tax ID is: 31-1451739 MEMBERSHIP FEES & SUBSCRIPTIONS Member Category USD Dues ☐ Young Scientist/Student $ 60.00 ☐ Developing Country Young Scientist $ 30.00 Membership Dues USD (A) Optional: Print Subscription to TDM Subscription Category USD Rate ☐ USA/Canada $224.00 ☐ Other Country $232.00 Print Subscription to TDM USD (B) Total Payment: (A)+(B) USD Send Completed Form And Payment: By Mail IATDMCT 4 Cataraqui Street, Suite 310 Kingston ON K7K 1Z7 Canada By Fax: +1-613-531-0626 By Wire: Account Name: IATDMCT Account No. 9844080995 Swift Code: MANYUS33 Branch: 1218 Address: M & T Bank Pittsford Branch Rochester NY 14618 USA Please go to page 2 MEMBERSHIP BENEFITS ALL IATDMCT MEMBERS RECEIVE: · Discount on subscription to Therapeutic Drug Monitoring · IATDMCT Compass, the official IATDMCT Newsletter · Access to on-line membership directory and “Members Only information section of the web page · Discount at biannual IATDMCT Congress · Access to unrivalled expertise in the field of therapeutic Drug monitoring and clinical toxicology · Opportunity to network with your colleagues from around the world · Opportunity to participate on scientific committees DEVELOPING COUNTRY CATEGORY To be eligible for the Developing Country category you must be a resident in one of the following countries:
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