Rua Sergipe 401 conjunto 808, São Paulo, SP, CEP 01243-906, Brazil
Phone/Fax: +55 11 3159.1653 (Brazil); Phone: +1 614 556 4445 (USA)
Web: http://www.iagp.com; E-mail: office@iagp.com
2009-2012 ORGANIZATIONAL MEMBERSHIP AND PAYMENT FORMS
Dear IAGP Affiliate Organization,
In addition to the professional networking opportunities offered by the IAGP, Organizational affiliates become
members of our Consultative Assembly of Organizational Affiliates (CAOA), and are 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. Organizational affiliates also receive a copy (one per
organization) of IAGP publications, and their organization is listed in our Website and in the next printed edition
of our membership directory. The IAGP operates a three-year billing cycle, corresponding to the interval between
our international congresses. Membership fees and forms for the 2009-2012 term are now due, and can be
submitted either:
1) Online (preferable)
Please go to http://www.iagp.com/membership, where you will find online versions of all the enclosed
forms, including a secure form to pay your dues by credit card.
2) By mail/fax
Please complete the enclosed forms (2 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$ which was sent to the IAGP’s bank in Singapore
Please feel free to send us queries and comments using the e-mail/fax/voicemail/postal addresses above.
FEES AND REDUCTIONS
The IAGP has adopted the World Bank’s rating of country income, as of July 2009, for determining
membership fees. (Please see below)
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
US$450
US$675
US$900
US$1,125
US$1,350
US$1,575
US$1,800
50% Dues
US$112.50
US$225
US$337.50
US$450
US$562.50
US$675
US$787.50
US$900
40% Dues
US$90
US$180
US$270
US$360
US$450
US$540
US$630
US$720
30% Dues
US$67.50
US$135
US$202.50
US$270
US$337.50
US$405
US$472.50
US$540
Full Dues:
Andorra, Antigua & Barbuda, Aruba, Australia, Austria, Bahamas, Bahrain, Barbados, Belgium, Bermuda, Brunei, Canada,
Cayman Island, Channel Islands, Croatia, Cyprus, Czech Republic, Denmark, Equatorial Guinea, Estonia, Faeroe Islands,
Finland, France, French Polynesia, Germany, Greece, Greenland, Guam, Hong Kong, Hungary, Iceland, Ireland, Isle of Man,
Israel, Italy, Japan, Korea Rep, Kuwait, Liechtenstein, Luxembourg, Macao, China; Malta, Monaco, Netherlands, Netherlands
Antilles, New Caledonia, New Zealand, Northern Mariana Islands Norway, Oman, Puerto Rico, Portugal, Qatar, San Marino,
Saudi Arabia, Singapore, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Trinidad & Tobago, Taiwan (R.O.C.), United
Arab Emirate, United Kingdom, United States, Virgin Islands (U.S.)
50% Dues:
Algeria, American Samoa, Argentina, Belarus,Bosnia & Herzegovina, Botswana, Brazil, Bulgaria, Chile, Colombia, Costa
Rica, Cuba, Dominica, Dominican Republic, Fiji, Gabon, Grenada, Jamaica, Kazakhstan, Latvia, Lebanon, Libya, Lithuania,
Macedonia, Malaysia, Mauritius, ,Mayotte Mexico, Montenegro, , Namibia, Palau, Panama, Peru, Poland, Romania, Russian
Federation, Serbia Seychelles, South Africa, St Kitts & Nevis, St. Lucia, St Vincent & the Grenadines, Suriname, Turkey,
Uruguay, Venezuela, RB
40% Dues:
Albania, Angola, Armenia, Azerbaijan, Belize, Bhutan, Bolivia, Cameroon, Cape Verde, China, Congo, Rep, Cote d’Ivoire,
Djibouti, Ecuador, Egypt, Arab Rep, El Salvador, Georgia, Guatemala, Guyana, Honduras, India, Indonesia, Iran, Iraq, Jordan,
Kiribati, Lesotho, Maldives, MarshallIslands, Micronesia, Moldova, Mongolia, Morocco, Nicaragua, Nigeria, Pakistan, Papua
New Guinea, Paraguay, Philippines, Samoa, Sao Tome & Principe, Solomon Islands, Sri Lanka, Sudan, Swaziland, Syrian
Arab Republic, Thailand, Timor-Leste, Tonga, Tunisia, Turkmenistan, Ukraine, Vanuatu, West Bank & Gaza
30% Dues:
Afghanistan, Bangladesh, Benin, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Comoros, Congo, De.,
Rep; Eritrea, Ethiopia, Gambia, Ghana,Guinea, Guinea-Bissau, Haiti, Kenya, Korea, Dem Rep; Kyrgyz Republic, Lao, PDR,
Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Myanmar, Nepal, Niger, Rwanda, Senegal, Sierra Leone,
Somalia, Tajikistan, Tanzania, Togo, Uganda, Uzbekistan, Vietnam, Yemen, Zambia, Zimbabwe
Form 666A4W v3.0
Page 1 of 4
Rua Sergipe 401 conjunto 808, São Paulo, SP, CEP 01243-906, Brazil
Phone/Fax: +55 11 3159.1653 (Brazil); Phone: +1 614 556 4445 (USA)
Web: http://www.iagp.com; E-mail: office@iagp.com
2009-2012 ORGANIZATIONAL MEMBERSHIP AND PAYMENT FORMS
PART 1: CONTACT AND PAYMENT DETAILS
PLEASE WRITE CLEARLY IN BLOCK (CAPITAL) LETTERS
SECTION A - CONTACT INFORMATION
Name of organization:_________________________________________________________________
Number of members: _________
Name of contact person: ______________________________________________________________
Address:___________________________________________________________________________
___________________________________________________________________________________
Telephone:________________________________ Fax: _____________________________________
E-mail:________________________________ Please retype e-mail: ___________________________
Comments:_________________________________________________________________________
___________________________________________________________________________________
SECTION B – TYPE OF MEMBERSHIP
Please indicate if you are a new or renewing organization: NEW _______
RENEWING _______
SECTION C – PAYMENT AMOUNT AND METHOD
Please select 1) or 2) below and fill in the relevant details:
1) PAYMENT BY BANK DRAFT/TRANSFER (YES/NO)
I am enclosing a photocopy of a bank draft/transfer for US$__________ (Please indicate sum, which
must be in US$). This was transferred to the account of the International Association for Group
Psychotherapy and Group Processes:
United Overseas Bank in Singapore
Bank Address: 80 Raffles Place, UOB Plaza, Singapore 048624
Account number: 352-903-737-4
Bank branch: Main Branch
Swift code: UOVBSGSG
OR
2) PAYMENT BY CREDIT CARD (YES/NO)
I hereby authorize you to deduct $ ____________ (Please indicate sum) from my card.
Type of credit card (Please select one):
VISA____
MASTERCARD_____
AMERICAN EXPRESS_____
Name on credit card:
______________________________________________
Number on credit card:
______________________________________________
Please retype credit card number: ______________________________________________
Expiry date: __________ CVV (3 -4 digit security code printed on the credit card):_______
Signed: __________________________________________________________________
Date: ________________________
Form 666A4W v3.0
Page 2 of 4
Rua Sergipe 401 conjunto 808, São Paulo, SP, CEP 01243-906, Brazil
Phone/Fax: +55 11 3159.1653 (Brazil); Phone: +1 614 556 4445 (USA)
Web: http://www.iagp.com; E-mail: office@iagp.com
2009-2012 ORGANIZATIONAL MEMBERSHIP AND PAYMENT FORMS
PART 2: ORGANIZATIONAL MEMBERSHIP DIRECTORY INFORMATION
Please fill out the form below for the next issue of the IAGP membership
directory. You may leave blank any areas that you do not want to appear in the
directory. PLEASE WRITE CLEARLY IN BLOCK (CAPITAL) LETTERS.
Name of organization
English translation of
name (if desired)
Address, part 1: number
and street/PO Box number
Address, part 2: city,
province/state (if
applicable), postal code,
country
Telephone (including
country code)
Fax (including country
code)
E-mail
Please retype e-mail
Website address
Name and contact details
of President
Please describe aims and
objectives in no more than
5 sentences.
Form 666A4W v3.0
Page 3 of 4
Rua Sergipe 401 conjunto 808, São Paulo, SP, CEP 01243-906, Brazil
Phone/Fax: +55 11 3159.1653 (Brazil); Phone: +1 614 556 4445 (USA)
Web: http://www.iagp.com; E-mail: office@iagp.com
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. Furthermore, I 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 as to the tax
implications for payment of the 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
required here to indicate acceptance of the above terms:
Signature______________________________________________________
Date__________________________
Form 666A4W v3.0
Page 4 of 4