[Please print out or re-write this form and send it to the IAAPA secretariat at: IAAPA, Vorbergstr. 9a, 10823 Berlin, Germany.]

Application for Membership in the

International Association Against Psychiatric Assault (IAAPA)

I hereby apply for membership in the International Association Against Psychiatric Assault (IAAPA).

With this application I accept the conditions of membership as laid down in the statutes of the IAAPA published on its official website www.iaapa.ch.
The annual membership fee is 10 Swiss Francs or 6 US$ or 6 Euro.
Bank account: IAAPA, Credit Swiss: Albangraben 1-3, Basel, #0060-997776-51

I enclose a photocopy of my I.D., which includes a photograph.

[Please use block letters:]

First Name: ....................................................................

Last Name: ....................................................................

E-mail address: ..............................................................

Date: ...............................................................

Signed: ...........................................................

[As soon as the secretariat receives your application by post, it will confirm receipt by e-mail.]