Membership Registration Form

First Name
Middle name / initials
Last name / Surname
Date of joining AfSHG (DD/MM/YYYY) (give year if not certain)
Institution / Business
University / Company name/
Department / Unit
Street
City (and State)
Postal / Zip code
Country
Email address
Title (Mr/Dr/Prof/etc.)
Position (RA/fellow, professor etc.)
Date of completion of degree or studies (students only; DD/MM/YYYY)
Main type of work
Research Clinical / Counselling
Teaching Administration
Areas of interest (select 2 or 3)
Molecular Genetics Clinical/Medical Genetics
Genetic Epidemiology Genetic Counselling
Statistical Genetics / Modelling ELSI (ethical/legal/social implications in Genetics)
Bioinformatics Pharmacogenetics
Population Genetics Other (specify)
Type of membership
Regular (individual from a developing country) $25
Regular (individual from Europe/North America) $125
Life (individual from a developing country) $250
Life (individual from Europe/North America) $1250
Institutional $250
Student/Trainee Free