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If you wish to be added or make an address change to the International Antiviral Society–USA mailing list, which includes CME course program announcements and issues of our publication, Topics in Antiviral Medicine®, please complete this form. All information requested must be provided. Mail or fax the completed form to:

Please check the appropriate box:

I am a new subscriber to the IAS–USA mail list
I am a current subscriber requesting a change of address
I am unsure of my status

Please check the Topics in Antiviral Medicine subscription type:

I would like to receive Topics in Antiviral Medicine in electronic form only (E-subcription, paperless)
I would like to receive Topics in Antiviral Medicine in both paper and electronic form

First Name

MI

Last Name

E-mail

IAS–USA ID Number
(if applicable - the number is located in the upper left corner of the IAS–USA mailing address label)

Degree or License (MD, RN, PA, none, etc)

Title/position

Institution/organization (no abbreviations please)

Specialty or primary field of interest

Currently, for how many HIV-infected patients are you providing care?

What percentage of your patients is HIV infected?

Mailing address  Home   Work

City

State

Zip

Country

Phone
   Home   Work

Fax
   Home   Work

Do you work for a commercial company? (eg, pharmaceutical, diagnostic, medical product, advertising, insurance, investment, or communications)    Yes    No
If yes, name of company (you will be sent additional course/registration information)

Type of company

Source Code: WEB 11