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Address:...................................................................................................

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Tel.: ............................................    Fax: ..................................................

e-mail: ......................................................................................................

http://.......................................................................................................

Address for correspondence, if different from above:   

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Tel.: ..............................................   Fax: ..............................................

e-mail: ...................................................................................................

http://....................................................................................................

President:............................................................................................

Address:...............................................................................................

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Tel.: ..............................................   Fax: .............................................

e-mail: ..................................................................................................

Secretary General:...........................................................................

Address:..............................................................................................

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Tel.: ..............................................   Fax: ............................................

e-mail: .................................................................................................

Treasurer:.........................................................................................

Address:.............................................................................................

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Tel.: ..............................................   Fax: ...........................................

e-mail: ................................................................................................

How often do your officers change? ....................... years

Number of individual members:.......................

Professions included:

• physicians
• psychologists
• other

Membership Category:

• Member organization with less than 100 members
• Member organization with 100 to 1000 members
• Member organization with more than 1000 members
• International umbrella organization