Taiwan Anti-Aging Association Membership Application Form

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Presentation transcript:

Taiwan Anti-Aging Association Membership Application Form Taiwan Academy of Anti-Aging www.t3a.org.tw Tel：886-2-2523-7680　Fax：886-2-2523-6832 Taiwan Anti-Aging Association Membership Application Form No____________ Name Sex □ Male　　　□ Female Birth day 　/　 / 　 (day/month/ year) Tel Fax Cell Phone E-Mail Address Address Education Experience Present Occupation Present Title Applicant Sign：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿ Date:　　　　　　　(day/month/ year) Fee (USD) Application Fee ７０　USD Yearly Fee ４０　USD 1 Wire the fee to the following account Bank: Taishin International Bank, Taiwan (Swift Code: TSIBTWTT ) Account No: 2002-0100-0015-66 Account Name: The Taiwan Academy of Anti-Aging Medicine 2 Fax the receipt or invoice to T3A.