"AFRICAN NUTRITION SOCIETY (ANS)"
AFRICAN NUTRITION SOCIETY (ANS) Please send completed application forms to: Africa Nutrition Society HQ, Customer Services, P.O.Box KB 18, Korle Bu, Accra, Ghana, West Africa Tel: +233 (0)244 872410; Fax: + 233 (0)21 513294 Email: firstname.lastname@example.org A professional scientific forum and voice for Africa’s nutrition and health MEMBERSHIP APPLICATION FORM 2011 FOR STUDENT/FULL/AFFILIATE MEMBERSHIP OF ANS *Membership runs from January to December EACH YEAR. You will receive your Welcome Pack and Membership Card by post within 28 days of receipt of this form by the membership office. Membership of the African Nutrition Society is open to any person who has an academic background in nutrition or related subjects including those allied to medicine with a genuine interest in the science of nutrition and its application to clinical and dietetic states, developmental biology and chronic disease, animal nutrition and health, the food industry, food security, nutrition and health policy. Membership is international and not restricted by race, colour, creed or nationality. I am applying to become a Student/Full/Affiliate member of the African Nutrition Society. I undertake to accept the rules and regulations in accordance with its Memorandum and Articles of Association. I understand that Council has the right to reject or suspend my membership. Signed Date DETAILS OF APPLICANT (Please complete in block capitals or print.) Title: Forename: Surname: Address 1: Address 2: Postcode: Country: Telephone (incl std code): Fax (incl std code): Email: Please tick if you do NOT wish to receive emails. Please note that the African Nutrition Society will use this postal and email address for important correspondence. Sex: Male / Female Which of the following best describes your place of work? (Please tick one) □ Higher Education/Research □ Healthcare/Public Health □ Government □ Media/Communications □ Industry □ Self-Employed □ Non-profit/Charity/Pressure Group □ Student □ Non-governmental Organization □ Food & Agriculture Sector Which of the following best describes your job? (Please tick one) □ Researcher/Research Co-ordinator □ PR/Media/Communications Specialist □ Lecturer/Teacher/Professor □ Administrator/IT Specialist □ Medical Doctor/Clinical Dietician/Nurse etc. □ Statistician/Methodologist □ Public Health/Health Promotions Specialist □ Product Development/Regulatory Affairs □ Marketing/Sales/Customer Care □ Research Student African Nutrition Society Registered Office: P. O .Box KB 18, Korle Bu, Accra, Ghana, West Africa Tel: +233244872410 Fax: +233 (0) 233 21513294. Email: email@example.com Website: www.answeb.org Registered in Accra No. Do you have another area of interest/expertise? (If not listed above): Would you like to join one or more of the African Nutrition Society Thematic Forums? □ Cellular, Molecular Nutrition & Metabolism □ Nutritional Epidemiology and Public Health □ Medical, Clinical & Applied Nutrition □ Nutrition, Media & Public Engagement □ Food Science, Food Chain & Animal Nutrition □ Maternal and Child Health & Nutrition □ International Nutrition & Global Health □ School Health & Nutrition □ Micronutrient Nutrition □ Food Security, Agriculture & Health Economics □ Community Health & Nutrition Education □ Emergency Nutrition If you join a Thematic forum your details will automatically be included in the list for correspondence and dissemination of theme-related information and activities. The success of the theme will depend on the collective activity of its members PAYMENT Annual Membership Costs for 2010 (From January 2011 – December 2011) Sterling (£)* Euros (€)** US Dollars ($) Full Membership □ 35 □ 42 □ 50 Student Membership (up to 2 years post graduation) □ 15 □ 18 □ 20 Affiliate Membership □ 32 □ 40 □ 45 Institutional Membership □ 75 □ 90 □ 100 PAYMENT TYPE □ Cheque (payable to African Nutrition Society) □ Credit/Debit Card (fill details out below. Please note a direct debit can be set up for renewals) Card Type (e.g. VISA) Expiry Date Start Date Cardholder’s Name Issue Number Card Number The card security code is a unique three or four-digit number printed on your credit Security Code card (above the signature strip at the back or above the account number at the front of the card). Total Amount (Specify currency) Please send this application to the African Nutrition Society Membership Office (address at top of form). If you have any queries, please call the African Nutrition Society Members email firstname.lastname@example.org