ISSPA Membership Application Form

MEMBERSHIP YEAR:
FROM:		TO:

I/We by signing this Application Form hereby apply for membership in ISSPA on and subject to the ISSPA's Articles of Association, as from time to time revised in accordance with such articles. I/We acknowledge and agree that the Articles of Association (as from time to time revised) shall form part of and shall accordingly be incorporated into this Application Form.

I/We understand that failure to adhere to the obligations and to the ISSPA's Code of Good Practice, may result in suspension or termination of membership rights in accordance with the Articles of Association.

1. APPLICANT INFORMATION

NAME OF APPLICANT CORPORATION:

PLACE OF INCORPORATION:		DATE OF INCORPORATION:

REGISTERED ADDRESS:

2. BRIEF DESCRIPTION OF BUSINESS

3. CURRENT RADIOACTIVE MATERIALS

LICENSE NUMBER:

ISSUING AGENCY:

EXPIRATION DATE:

4. CONTACT PERSON AND DESIGNATED ISSPA REPRESENTATIVE

NAME:

TITLE:

ADDRESS:

TELEPHONE:		FAX:		E-MAIL:

Please NOTE: By submitting this application you are stating that you have read and understand the declarations below.

	I/We declare that the Applicant is not a subsidiary of another current member of ISSPA. As a member of ISSPA Applicant declares that it will work to support the mission statement and objectives of the ISSPA and conduct its activities with respect to the Association in accordance with the ISSPA Code of Good Practice, and agrees to indemnify and hold harmless the ISSPA and its members harmless of any damages or claims suffered arising from the conduct of Applicants activities.
	I/We acknowledge that Membership fees (currently 2,000.00 Euro) are due annually, may be automatically renewed, and are payable within 90 days from the date of Request of Payment. Notice of the applicable renewal fee shall be provided prior to renewal. Termination of membership shall be provided in writing.
	I/We acknowledge that we have read and agree to comply with the ISSPA Articles of Association, and are authorized by Applicant to apply on behalf of the Applicant, for the purpose of membership. I/We understand that all new members must be approved by a majority of the existing membership.

APPLICANT NAME:		DATE: