On-Line Membership Application Form

Date:   2017-May-26_11:26:57

Basic Information

First Name (Required):

Last Name (Required):

Chinese Name:
Birthday (Required): Month   Day
E-Mail (Required):

Gender:

Male    Female

 

Contact Information

Title:
Department:
Institute (English) (Required):
Institute (Chinese):

Address (English):
Address (Chinese):
City:
State:
Zip Code:
Country:
Country Code:
Area Code:

TEL (Required):

FAX:

Web Site

 

Membership Information

Apply for the year(yyyy) (Required):
Member Type (Required):
Payment Method:
Member Fee:  
 

Credit Card Information

Card Type:
Card Number:(with no spaces in between)
Expiration Date(mm/yy):
Validation Number (last 3 digits nearby the signature):