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Subscription request form:

Mr. Mrs Miss

Name*

First Name*

Title*

Organisation*

Function

Address*

City*

ZIP*

Country*

Phone (professionnal)

Fax

E-mail*

Invoicing address
(if different from above)

APGI subscription for year(s)*:

Cotisation fee

Please select one of the member categories below*

1 year

3 years

Active Member

Industry

165 euros

495 euros

Academia, Hospital, Pensioner

70 euros

210 euros

Recent Graduates
(postgraduate diploma since less than 2 years)
25 euros

75 euros

Correspondent Member
200 euros

600 euros

Benefactor Member
500 euros

1500 euros

Yes, I would like to subscribe and pay for 3 years, this to avoid any increase of the fee during this period

* Required files

	Mr. Mrs Miss
Name*
First Name*
Title*
Organisation*
*Function*
Address*
City*
ZIP*
Country*
*Phone (professionnal)*
*Fax*
E-mail*
*Invoicing address* (if different from above)
*APGI subscription for year(s):**
		Cotisation fee
Please select one of the member categories below*		1 year	3 years
	Active Member
	Industry	165 euros	495 euros
	Academia, Hospital, Pensioner	70 euros	210 euros
	Recent Graduates (postgraduate diploma since less than 2 years)	25 euros	75 euros

	Correspondent Member	200 euros	600 euros
	Benefactor Member	500 euros	1500 euros

	Yes, I would like to subscribe and pay for 3 years, this to avoid any increase of the fee during this period
* Required files