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| <HTML> | |
| <HEAD> | |
| <META HTTP-EQUIV="Content-Type" CONTENT="text/html; charset=iso-8859-1"> | |
| <META NAME="GENERATOR" CONTENT="Mozilla/4.01 [en] (Win95; I) [Netscape]"> | |
| <TITLE>WINDOWS\Desktop\stree\fellow</TITLE> | |
| </HEAD> | |
| <BODY TEXT="#00006B" BACKGROUND="back.gif"> | |
| <CENTER> | |
| <H2> | |
| FELLOWSHIP, MEMBERSHIP, SUBSCRIPTION INFORMATION</H2></CENTER> | |
| <CENTER><IMG SRC="line.gif" HEIGHT=7 WIDTH=535></CENTER> | |
| <P><B><FONT SIZE=+0>FELLOWSHIP</FONT> in The American Institute of Stress | |
| is available to health professionals and other qualified individuals with | |
| appropriate evidence of advanced education, training, skills or related | |
| experience in a stress related area. Please submit a CV or resumé, | |
| with biographical data, reprints of publications or other supportive information | |
| for review by our Accreditation Committee. Fellows will receive a complimentary | |
| subscription to our monthly <A HREF="news.htm">Newsletter</A>, | |
| and reduced rates for <A HREF="info.htm">Informational | |
| Packets</A>, selected publications and meetings, and a Certificate of Fellowship | |
| suitable for framing. The Fellowship fee is $90.00.</B> | |
| <P><B><FONT SIZE=+0>MEMBERSHIP</FONT> in The American Institute of Stress | |
| is available to anyone and provides a complimentary subscription to our | |
| monthly <A HREF="news.htm">Newsletter</A>, and | |
| reduced rates for <A HREF="info.htm">Informational | |
| Packets</A>, selected publications and meetings. <FONT SIZE=+0>SUSTAINING | |
| MEMBERSHIP</FONT> is available for $100 annually, and includes the above | |
| and 2 additional free Newsletter subscriptions.</B> | |
| <CENTER> | |
| <H3> | |
| Tell Us About Yourself and Your Interests</H3></CENTER> | |
| <FORM METHOD="POST" ACTION="http://206.103.159.24/scripts/mailform.exe"> | |
| <input type=hidden name="email" value="Fellow"> | |
| <input type=hidden name="subject" value="Fellow"> | |
| <input type=hidden name="mailto" value="stress125@earthlink.net"> | |
| <input type=HIDDEN name=HTTP_REFERER value=CGI.REMOTE_HOST> | |
| <!FORM method="POST" action="_vti_bin/shtml.exe/fellow.htm" webbot-action="--WEBBOT-SELF--"><!--webbot bot="SaveResults" S-Email-Address="stress124@earthlink.net" S-Email-Format="TEXT/PRE" startspan --><INPUT TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--webbot bot="SaveResults" endspan i-checksum="43374" --><INPUT type="hidden" name="$File$" value="sTemplate.txt"><INPUT type="hidden" name="$Subject$" value="INFO Request"><INPUT type="hidden" name="$LocationOK$" value="/ok.html"><INPUT type="hidden" name="$LocationKO$" value="ko.html"><INPUT type="hidden" name="$Optional$" value="mmmh, no!"><INPUT type="hidden" name="$To$" value="stress124@earthlink.net"> | |
| <P><B>Surname/Family name:</B> <INPUT type="text" size="30" maxlength="30" name="$last_name$"> | |
| <P><B>First name and initials: </B><INPUT type="text" size="30" maxlength="30" name="$first_name$"> | |
| <P><B>Degree(s), title(s), affiliation: </B><INPUT type="text" size="40" maxlength="40" name="$degree$"> | |
| <P><B>Street:<INPUT type="text" size="40" maxlength="40" name="$street$"></B> | |
| <P><B>City:<INPUT type="text" size="30" maxlength="30" name="$city$"></B> | |
| <B>State:</B><INPUT type="text" size="2" maxlength="2" name="$state$"> | |
| <P><B>Zip:<INPUT type="text" size="10" maxlength="10" name="$zip$"></B> | |
| <B>Country: </B><INPUT type="text" size="10" maxlength="20" name="$country$"> | |
| <P><B>Telephone Number:</B><INPUT type="text" size="30" maxlength="30" name="$tel$"> | |
| <P><B>Fax: </B><INPUT type="text" size="30" maxlength="30" name="$Fax$"> | |
| <P><B>E-mail:<INPUT type="text" size="30" maxlength="30" name="$email_from$"></B> | |
| *required | |
| <P><B>Areas of Interest:</B> <INPUT type="text" size="50" maxlength="50" name="$interest$"> | |
| <BR>(Please indicate your particular interests. Some examples include: | |
| Basic research, Physician or other health care professional, Alternative | |
| Medicine, Provider of Services (describe), Product Manufacturer (describe), | |
| etc. List all that are appropriate.) | |
| <H3> | |
| I am interested in:</H3> | |
| <B>Monthly Newsletter Subscription: </B><INPUT type="checkbox" name="$subscription$" value="YES"> | |
| <BR>(Subscription $35.00, Overseas $45.00) | |
| <P><B>E-Mail Newsletter Version: </B><INPUT type="checkbox" name="$email_subscription$" value="YES"> | |
| <BR>(Send information on e-mail Newsletter ($15) when available) | |
| <P><B>Fellowship and Membership: </B><INPUT type="checkbox" name="$fellowship$" value="ON"> | |
| <BR>(Fellowship $90, Membership $75, Sustaining Membership $100) | |
| <P><B>Details about the 10th Annual Congress on Stress in Montreux, Switzerland, | |
| 1998: </B><INPUT type="checkbox" name="$congress$" value="YES"> | |
| <BR>(Send brochure about the next Congress when available) | |
| <P><B>The following individuals should be included in your Directory</B> | |
| <BR>(List name, address, fax, e-mail and any other information.) | |
| <BR><B>First </B><INPUT type="text" size="70" maxlength="150" name="$who_one$"> | |
| <BR><B>Second </B><INPUT type="text" size="70" maxlength="150" name="$who_two$"> | |
| <BR><B>Third </B><INPUT type="text" size="70" maxlength="150" name="$who_three$"> | |
| <P><INPUT type="submit" value="SUBMIT"><INPUT type="reset" value="RESET"> | |
| <BR></FORM> | |
| <P>Please send check or money order payable to: The American Institute | |
| of Stress, 124 Park Ave., Yonkers, NY 10703. (We do not currently accept | |
| credit cards). The American Institute of Stress is a non profit organization, | |
| and all contributions are tax deductible to the extent provided by law. | |
| <CENTER></CENTER> | |
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| | |
| <CENTER><TABLE BORDER=0 CELLSPACING=7 CELLPADDING=7 > | |
| <TR> | |
| <TD ALIGN=CENTER colstart="1"><B><A HREF="index.html">Homepage</A></B></TD> | |
| <TD ALIGN=CENTER colstart="2"><B><A HREF="news.htm">Newsletter</A></B></TD> | |
| <TD ALIGN=CENTER colstart="3"><B><A HREF="who.htm">Directory | |
| and Other Networking Links </A></B></TD> | |
| </TR> | |
| </TABLE></CENTER> | |
| | |
| <HR> | |
| <CENTER> | |
| <P><B><I>Site hosted by:</I> <A HREF="http://www.powersite.net"></FONT></FONT><FONT COLOR="#000000">PowerSite Internet Services, Inc.</FONT></A></B> | |
| <BR><B><I>Any questions or comments about this site <A HREF="mailto:questions@stress.org"><FONT COLOR="#FF0000"><FONT SIZE=+1>Click | |
| Here</FONT></FONT></A></I></B> | |
| <BR><B><I>All rights reserved. All trademarks are owned by the respective | |
| company</I></B></CENTER> | |
| </BODY> | |
| </HTML> |