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International Parkinson and Movement Disorder Society
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Affiliate Membership Interest Form

Please provide the name and contact information for the representative of the Society seeking Affiliate Membership Status with MDS. After you have submitted this information, a member of the International Secretariat will be in contact with you.

Please note: By submitting this form, you are simply noting your interest in becoming an Affiliate Society member of MDS and your application is not yet complete.  If you have any questions, please contact education@movementdisorders.org.
 

An asterisk (*) indicates required information

Society Contact Name*
Society Contact Role/Position*
Society Name*
Society Contact Company*
Company or Society Address*
Company or Society City*
Company or Society State/Province*

Company or Society Country*
Telephone*
Fax
E-mail*