American Association of Tissue Banks …

                   American Association of Tissue Banks
                 1320 Old Chain Bridge Rd., Suite 450, McLean, VA, 22101; Phone 703-827-9582; Fax 703-356-2198

                                    2008    APPLICATION FOR INDIVIDUAL MEMBERSHIP

                                     Individual annual dues fee: $185.00 (U.S. DOLLARS)

Instructions: Please type or print clearly. Annual dues made payable to the American Association of Tissue Banks must accompany this
application. Application must be completed in full to the best of the applicant's knowledge; incomplete applications will be returned.

Individual membership is open to those who support the objectives, policies, and ethical standards of the Association and who share the
stated purposes of the Association, which are to promote scientific and technical knowledge concerning the retrieval, processing, storage,
distribution, transplantation, and evaluation of cells, tissues, and organs, and to make available through regional tissue bank programs a
safe, adequate, and economical supply for clinical and research purposes.


Name:
                   Last                                              First                                MI           Degree
Organization:
Address:


City:                                                                        State:                Zip Code:
Telephone: (                    )                                  Ext:                Fax: (         )
E-mail Address:
Present Position or Status:
Principal Specialties or Interests in Tissue Banking:



Academic Career:(Institution)                                                         Degree:                     Date




Council (please check ONE only):

                 Musculoskeletal                                                 NOTE: You must be on one of the five councils
                 Skin                                                                 listed, but can serve only on one. Please
                 Reproductive                                                         select the one that best suits your area of
                 Tissue Bank (includes cardiovascular,                                interest.
                 blood, and other cells, tissue, and organs)
                 Physicians' (if MD)

I concur with and support the objectives, policies, and ethical standards of the American Association of Tissue Banks.


                           Signature of Applicant                                                         Date

                                                        PAYMENT METHOD

           My check is enclosed in the amount of: $

           VISA, MC, or AmEx #:                                                                            Exp Date:

            Signature of Cardholder: