(LAST)                 (FIRST)              (MIDDLE INITIAL)

Salutation________________ (Dr, Prof., Mrs, Ms, Mr, ...)

Date of birth____________________________________________(month day year)

Highest academic degrees_________________________________

Position_________________________________________________

Affiliation:_____________________________________________(laboratory)

            _____________________________________________(department)

            _____________________________________________(Univ., Hosp., Comp.)

Address:________________________________________________ (building/room)

        ________________________________________________ (street address)

        ________________________________________________ (PO or local mail box)

        _________________________________________________(city; Zip/postal code)

        _________________________________________________(state/province)

        _________________________________________________(country)

If you wish your mail to be sent to another address, please give it hereunder and state
whether that address can be included in the public ISAP membership list.

          ______________________________________________________________

          ______________________________________________________________

          include in public ISAP membership list: Yes /No

Telephone: ___________________(direct; please state country code and city code)

           ___________________(secretary)

           ___________________(main institution switchboard)

Fac-simile ___________________

E-mail address__________________________________________(please, spell legibly)

Internet Web site_________________________________________________________

Present major activities in Anti-Infective Pharmacodynamics/Pharmacokinetics

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

List a max. of 3 of your publications dealing with the interests of ISAP

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Keywords for entry of your scientific interests in ISAP membership database (max. 5)

_________________________________________________________________________________

Sponsor #1 name_______________________________________________________________

           address____________________________________________________________

                  ____________________________________________________________

                  ____________________________________________________________

Sponsor #2 name_______________________________________________________________

           address____________________________________________________________

                  ____________________________________________________________

                  ____________________________________________________________

Upon acceptance by the Council, the applicant will be notified and requested to pay his/her initiation fees to cover membership dues for the remainder of the current year
(yearly dues are 100 EUROS at this time [August 2006] ); do not send payment now.

________________________________________________________      __________________________

            (Applicant signature)                                     (date)

Enclose:

• a two page summary (preferably two-sided) of your Curriculum Vitae
• a bibliography of recent relevant publications (two pages maximum).

ISAP Secretariat
c/oCongress Care
PO Box 440
5201 AK 's-Hertogenbosch
The Netherlands
fax +31-73-6901417
mail j.vandermeer@congresscare.com

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