International AIDS Society-USA
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Mailing List

If you would like to receive notification of new CME activities sponsored by the IAS-USA and a complimentary subscription to Topics in HIV Medicine, please complete the following form.

*=Required Field

List Status
I do not currently receive information about IAS-USA programs by mail.
I am on the IAS-USA mailing list and wish to update my information.
          Mailing List ID (if known):

Name
* Salutation
Mr   Ms   Dr  
* First name:
Middle initital or name:

* Last name:
* Professional or academic degrees (select all that apply)
MD   DO   PharmD   RN   NP   PA   PhD  
None   Other (specify):

* Title: (Medical Director, Associate Professor, Program Coordinator, etc.)

* Institution or Organization:
* Specialty or primary field of interest:
U.S. Licensed Physician?    Yes    No
Mailing Address
* Street Address:
* Is this a home or work address?

Other: (PO Box, Floor #, Mail Stop, etc.)

* City:

* State (US only):
* State/Province outside US:

Postal Code:      Country (Outside US):

Phone / Fax / E-mail
Phone: Fax:

* E-mail address:

Practice Information
* Currently, for how many HIV-infected patients are you providing care?
* What percentage of your practice is devoted to the care of HIV-infected patients?

Affiliations
* Do you work for a commercial company? Yes No
(eg, pharmaceutical, diagnostic, medical product, advertising, insurance, investment or communications)
If yes, please indicate company name:

List Subscription * Would you like to receive paper announcements of IAS-USA courses and a complimentary subscription to Topics in HIV Medicine, the IAS-USA publication?
Yes No Already Do

* Would you like to receive e-mail announcements of IAS-USA live courses in your area?
Yes No

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