ILADS - International Lyme And Associated Diseases Society

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Application for Membership

The principal objective of the International Lyme and Associated Diseases Society is to serve physicians, scientists, and allied health personnel who are engaged in the diagnosis and treatment of Lyme and associated diseases.

Classifications and Requirements of Membership

Applications for membership in the Society will be submitted for review by the Credentials Committee and approval by the Board of Directors of ILADS. In addition to high ethical standards, members of the Society shall be either physicians (MD or DO) or research scientists (PhD) active in the advancement of Lyme and associated diseases or immunologic sciences and shall meet the requirements of the Credentials Committee.

Required Documents:

A copy of your most recent license renewal
A paragraph or so about who you are (such as what you are interested in, why you would like to join ILADS, what you hope to give and to receive from ILADS)
A copy of your updated CV

Please print this form after completion (it may not be submitted electronically at this time).
Mail the completed form, all required documents, and the membership fee to:

Judith Leventhal, PhD
205 East 63rd Street
New York, NY 10065
jgleventhalphd@gmail.com

Date

Name Email

Classification of membership requested:

Sustaining members are non-medical personnel who are highly involved with the field.
Student category consists of medical students and residents/fellows.
Affiliate consists of allied health care, ie Non-MD, Non-DO, Non-PhD, healthcare providers.
Regular membership is the only category that votes. They consist of MD, DO, PhD in direct patient care or Lyme research, DDS, DMD, and veterinary medicine docs.
Professional category includes JD, CPA, and Phd's that do not deal directly with Lyme disease patient care or research.

Fee:

$100 (Sustaining)

$100 (Student)

$150 (Affiliate)

$150 (Professional: JD,CPA, and PHD)

$200 (Regular)

$1000 (Corporate)

Name Degree Email

Office Address Phone

Address line 2 City

State Zip Code Fax

Home Address City

State Zip Code Phone

Type of Practice

Certifications
1. Year
2. Year
3. Year
4. Year

Schools
BA BS Year
DO MD PhD Year

Residencies
Type Year
Type Year
Type Year
Type Year

Medical/Scientific Societies
Dates
Dates
Dates
Dates

Courses/Training Related to Lyme Disease
Year
Year
Year
Year

Application fees will be refunded if membership is not approved.

Signatures:
Applicant ______________________________
Sponsor ______________________________	Phone _____________________
Sponsor ______________________________	Phone _____________________
Note: Student and affiliate membership applicants require a sponsor. Please refer to membership for complete information.

Do you know anyone who would like to receive information about ILADS? If so, please write his or her name, address, and email address on the lines provided below:

Name Street City, State, Zip Email
_____________________ _____________________ ____________________ __________
_____________________ _____________________ ____________________ __________
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