Iowa Physiological Society
Membership Application Form
Please print and mail the membership application to: Harald M. Stauss,
MD, PhD, Department of Exercise Science, University of Iowa, 410 Field
House, Iowa City, IA 52242. The check(s) (for $10.00) should be made out to
Iowa Physiological Society, Harald M. Stauss.
Applicants for Regular Membership with neither APS Membership nor a
higher academic degree should include written recommendations from two
Regular IPS Members.
Full Name:
_______________________________________________________________________
Signature:
__________________________________________________________________
Date: __________________________
Address:
_________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Telephone Numbers (Office): ________________________
(Home):
___________________________
FAX: ______________________________
E-mail:
________________________________________
Institution or Company:
__________________________________________________________
Highest Academic Degree: _________________
Check here if a Regular APS Member: _________
Membership type requested:
Regular (Voting Include $10-dues check to IPS)______
Student______
For Student Membership Only:
1. Advisor's Name and Affiliation:
____________________________________________
________________________________________________________________________________
2. Advisor's Signature Endorsing your Membership:
________________________________________________________________________________
