MEMBERSHIP APPLICATION
– HOW TO JOIN –
For your convenience we offer three easy ways to join.
- Complete the application and click "Submit Application" to submit it electronically.
- Complete the application, print and FAX to (201)865-3961
- Complete the application, print it and mail with the appropriate membership fee, made payable to:
THE INTERNATIONAL MEDICAL SPA ASSOCIATION
310 - 17th STREET • UNION CITY, NJ 07087
Phone: 201/865-2065 • Fax: 201/865-3961
Email: MedSpaAssn@aol.com
www.medicalspaassociation.org
Your membership package, including current benefits, will be sent to you within 2-3 weeks.
Dual membership rates with the Day Spa Association available. Please contact the IMSA/DSA office at (201)865-2065 for further details.
I am joining as a Medical Spa/Clinic. I understand my membership is transferable to another person within my organization.
I am enclosing information on my business. All benefits as described in the list of membership benefits will apply
Annual fee $350.00
Add'l person $75.00
Add'l location listings $175.00 ea.
I am joining as a Supplier/Service Provider to the Industry.
I understand my membership is transferable to another person within my organization.
I am enclosing information on my business All benefits as described in the list of membership benefits will apply
Membership fee $475.00
Add'l person $75.00
Add'l category listings $175.00 ea.
I am joining as an individual.
I understand that my membership is not transferable and that I will be listed under my home address and contact information. All benefits as described in the list of membership benefits will apply, except there will be no link to a website .
Membership Fee $225.00
PLEASE NOTE: Information submitted on this application will be reflected on the IMSA website. Please clearly indicate any information you do not want to appear on our website, such as private phone numbers or similar.
Full Name:
Title:
Company:
Address:
City/Province:
State:
[select best answer from list]
AL-Alabama
AK-Alaska
AR-Arkansas
AZ-Arizona
CA-California
CO-Colorado
CT-Connecticut
DC-Washington D.C.
DE-Delaware
FL-Florida
GA-Georgia
HI-Hawaii
IA-Iowa
ID-Idaho
IL-Illinois
IN-Indiana
KS-Kansas
KY-Kentucky
LA-Louisiana
MA-Massachusetts
MD-Maryland
ME-Maine
MI-Michigan
MN-Minnesota
MO-Missouri
MS-Mississippi
MT-Montana
NC-North Carolina
ND-North Dakota
NE-Nebraska
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NV-Nevada
NY-New York
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
PR-Puerto Rico
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VA-Virginia
VT-Vermont
WA-Washington
WI-Wisconsin
WV-West Virginia
WY-Wyoming
Country:
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic of,
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of,
Moldova, Republic of,
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of,
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Viet Nam, Socialist Republic of
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Zip Code:
Telephone:
Fax:
Email:
Website:
I was referred by the following IMSA member:
I am enclosing my check in the amount of US$
Please charge my credit card in the amount of US$
Card Type:
Visa
Master Card
Discover
Card#:
Exp. (mm/yy):
Security code (3 digits):
I am applying for membership in the International Medical Spa Association, have read the Code of Ethics and agree:
To adhere to and be governed by the International Medical Spa Association Code of Ethics.
To place the safety of my guests, patients and clients ahead of any other consideration.
To support the organization in its efforts to improve the quality of the medical spa industry
Please include a list of organizations with which you are currently affiliated when submitting your application.
Signature of Applicant:
Date: 3/11/2010 7:58:57 PM