Treasurer of IAGP, R. Sergipe 401, conjunto 808, São Paulo, SP, CEP: 01243-906, Brazil
T/F: +55 11 3159 1653 (Brazil); Email: treasurer@iagp.com
TERM 2012 – 15
ORGANISATIONAL MEMBERSHIP REGISTRATION AND PAYMENT
BENEFITS of MEMBERSHIP
In addition to professional networking opportunities, Organizational affiliates become:
Members of our Consultative Assembly of Organizational Affiliates (CAOA),
Closely involved in IAGP planning and decision-making through representation at Board meetings (via the CAOA chair), at CAOA
meetings, and in the CAOA online discussion forum.
IAGP membership also entitles you to:
1. Forum [our annual yearbook]
2. Globeletter [our informal newsletter]
3. Access to our membership directory and an organisational entry
4. Subscription to our members-only email announcement list, as well as new Internet services and digital
benefits to be announced soon.
COST
* IAGP has adopted the World Bank’s rating of country income, as of July 2009, for determining membership fees.
Please check your country to calculate your dues.
Number of members
Less than 50 members
50-100 members
101-200 members
201-400 members
401-600 members
601-800 members
801-1000 members
Over 1, 000 members
Full Dues
US$225.00
US$450.00
US$675.00
US$900.00
US$1125.00
US$1350.00
US$1575.00
US$1800.00
50% Dues
US$112.50
US$225.00
US$337.50
US$450.00
US$562.50
US$675.00
US$787.50
US$900.00
40% Dues
US$90.00
US$180.00
US$270.00
US$360.00
US$450.00
US$540.00
US$630.00
US$720.00
30% Dues
US$67.50
US$135.00
US$202.50
US$270.00
US$337.50
US$405.00
US$472.50
US$540.00
REGISTERING and PAYING
The IAGP operates a three-year billing cycle, corresponding to the interval between our international congresses.
Membership fees and forms for the 2012-2015 term can be submitted either:
Online (SIMPLER)
Please go to http://www.iagp.com/membership, where you will find a link to the online version of the enclosed forms,
including a secure form to pay your dues by credit card
OR
By mail/fax
Please complete all the enclosed forms (3 pages), and send them to the above postal address/fax number. You will be
asked to provide your credit card details, or to enclose a photocopy of a banker’s draft/transfer in US dollars as sent to
the IAGP’s bank in Switzerland.
PAYMENT METHOD
Are you a new or renewing member? Please tick.
Document1
NEW  or RENEWING 
Page 1 of 3
Please select 1) or 2) below and fill in the relevant details:
PAYMENT BY BANK DRAFT/TRANSFER
I enclose a photocopy of bank draft/transfer for US$
. This amount, which must be in US Dollars,
was transferred to the account of International Association for Group Psychotherapy and Group Processes at:
Bank: UBS-AG - Corporate Switzerland
Account number: CH16 0021 7217 1021 3660 E
Bank branch: Kreuzlingen branch
Bank Address: Bermerstrasse 27, 8280 Kreuzlingen, Switzerland
SWIFT/BIC UBSWCHZH80A
PAYMENT BY CREDIT CARD
I hereby authorize you to deduct US $ (Please indicate sum, which must be in US Dollars) from:
Type of credit card (Please tick one):
VISA  MASTERCARD  AMERICAN EXPRESS 
Name on card:
Card number:
Please retype card number:
Expiry date: CVV (3-4 digit security code printed on back of card):
Signed:
Date:
CONTACT DETAILS and INFORMATION for ORGANISATIONAL MEMBERSHIP DIRECTORY: Please write clearly in block
(capital) letters
Please leave blank any areas that you do not want to appear in the directory.
Name of organisation
English translation of name
(if desired)
Number of members
Name of Contact Person
Address
Number and street/PO Box
City, country, post code
Telephone
Fax
Email
Please retype Email
Website address
Name and contact details
of President
Please describe aims and
objectives in no more than
5 sentences.
Comments
Document1
Page 2 of 3
PAYMENT TERMS and CONDITIONS
Payment of the fee for all categories of membership are established by the terms set forth on the first page of this
form provided by the International Association for Group Psychotherapy and Group Processes, here forth referred to
as IAGP. All categories of membership are not transferable.
I understand that by completing the payment information, when payment is by credit card, I authorize the IAGP to
charge the appropriate fees to my designated credit card. Membership itself does not become activated until the
actual monies, authorized by credit card payment or via bank draft, are received by IAGP and confirmation of the
payment is issued to the payee from the administrative Office of IAGP.
I also understand that fees paid to IAGP are non-refundable, even in the event of discontinuation of membership
because of illness, death, dissolution of the paying professional Organization in the case of Organizational
membership, change in professional status or practice, or resignation. In accordance with IAGP by-laws, in the event
of dissolution of this Association monies cannot be returned, since they must be transferred to a charitable
organization.
IAGP is incorporated in Switzerland and has been granted the status of a Swiss tax-exempt charity (Reg. No.
409/2003). Please consult your personal tax consultant in your country about the tax implications for payment of
dues.
I understand that the bank used by IAGP to collect payment of fees may be in a country other than Switzerland. Any
questions, disputes, or inquiries about payments should be directed to:
The Treasurer of IAGP, R. Sergipe 401, conjunto 808, São Paulo, SP, CEP: 01243-906, Brazil
Phone/Fax: +55 11 3159.1653 (Brazil); Phone: +1 614 556 4445 (USA); E-mail: treasurer@iagp.com.
I have read these terms and conditions of payment above and the information supplied on the first page of this form.
A signature of an Officer or duly appointed representative of the Organization is required to indicate acceptance of
the above terms.
Signature
Date
Document1
Page 3 of 3