ISHV - Membership Form

Title
First Name
Surname
Date of Birth	Day Month Year
Gender	Female Male
Nationality
Profession
Organisation
Address
Code
City
Country
Phone number
Fax number
E-mail address
Additional information, which the organisation should know

REGISTRATION FEE US $20

Please pay into account no. 279-CA105601.0 of International Society for Human Values with:

UBS. S.A.
Palais des Nations, 12-18 avenue de la Paix
1211 Geneva, Switzerland
Swift code UBS WCHZH12A

Please, indicate the date of payment effected

Please send this form by e-mail or fax it to: +41 22 730 0354