Please complete and submit the following form to join the PNIRS. means that field is required

The process for joining is as follows:

• Complete the form below and click 'continue';
• On clicking 'continue' you will be taken to a secure payment page at Authorize.net where you can pay the subscription by credit card;
• Alternatively you can complete the form and then send a check to the address given on the Dues and Payments page;
• The PNIRS will review your application and respond back to you within the next month either confirming or declining your membership.

If you have any questions on any of the above please do note hesitate to contact PNIRS@umcutrecht.nl

Select a Membership Type	2008 PNIRS regular subscription ($182.00) Regular subscription for 2008 to the PNIRS including electronic subscription to Brain Behavior and Immunity. Please note if you are a first-time member, BBI access will be activated AFTER membership is confirmed by PNIRS membership committee 2008 PNIRS trainee subscription ($42.00) Trainee subscription for 2008 to the PNIRS including electronic subscription to Brain Behavior and Immunity. Please note if you are a first-time member, BBI access will be activated AFTER membership is confirmed by PNIRS membership committee
Payment System	Authorize.Net Web Payment - credit card via authorize.net
Your Name Your First & Last name
Your E-Mail Address A confirmation email will be sent to you at this address
Street
City
State	[Select State] Outside US and Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip or post code
Country	[Select Country] United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Congo (DRC) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands (British) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe
Department Department within organisation
Institution/affiliation	required
Telephone number (day/work)	required
Fax number
Title	Dr Prof Mr Miss Mrs
Degrees Qualifications and degrees (e.g. PhD, MD)
Your current status Please indicate your current status by selecting one of the options listed.	Please select from: Scientist Physician Lecturer Graduate Student Medical Student Postdoctoral Researcher None of the above
Training & Employment History Please give a brief outline of your training and employment history to date
Peer-reviewed publications Do you have a minimum of three peer-reviewed publications in the fields of either Psychology, Neurobiology or Immunology?	Please select from: yes no
Publications Please list your peer-reviewed publications in the fields of psychology, neurobiology or immunology
Name of proposer Regular membership applications Please provide name of regular member in good standing who will submit recommendation letter. Trainee membership applications Please provide name of mentor or chair of dissertation committee, and their title and university/hospital affiliation, who will submit a recommendation letter.
Professional/research interests These will appear under your entry in the membership directory and will be searchable by other members