International Phototherapy Association
AN INTERNATIONAL ASSOCIATION FOR LASER SURGERY, PHOTOTHERAPY AND PHOTOBIOMODULATIONJOIN IPTA!
Information and Application FormThe International Phototherapy Association (IPTA) will strive to uphold the rigorous professional standards of its illustrious predecessor, the International Laser
Therapy Association(ILTA). Our association respects the due democratic process andwelcomes the enrollment of a truly professional membership who is dedicated not
only to laser therapy, but also to the clinical and basic scientific research of all
aspects of phototherapy and photobiomodulation. The IPTA Congress will be held inodd years. The WALT holds their congress in even years, and hence we will hold IPTAin odd years. It is our earnest hope, however, that WALT and IPTA can work together
as a team. The reason why we established the new Association was to meet the expectation of the international needs for an association which will be dedicated to pure
LLLT, phototherapy, photodynamic therapy (PDT) and photobiomodulation. We therefore invite interested professionals to apply for membership, with an annual fee of¥12,000 (Japanese yen … about US $120) which will also include four issues per yearof the official IPTA journal, Laser Therapy. There is no initial processing fee. Anyone
working in the field of phototherapy, including laser therapy, either in clinical practiceor in basic research, is eligible to apply. This includes physicians, dentists, sports
clinicians, veterinarians, physiotherapists, physical therapists, PDT specialists, podiatrists, nurse specialists, research scientists and so on.

The option to join as a Life Member is also offered, whereby payment of 10 years’
Membership in advance (¥120,000) will entitle you to Membership of IPTA for life,
including receipt of the official journal for as long as you remain a member. Your
name will also appear permanently on the IPTA Roll of Honour in recognition of youroutstanding support for the Association.

Don’t hesitate, fill in and send off the form overleaf, join IPTA today, and become oneof the growing number of health professionals who see IPTA as a solid forum for theclinical and basic scientific aspects of all facets of phototherapy and photobiomodulation!

JOIN IPTA!

INTERNATIONAL PHOTOTHERAPY ASSOCIATION (IPTA)MEMBERSHIP APPLICATION FORM
(Please print or type clearly)

Name (Underline Last Name): ______________________________________________________________________________

Title (Mr, Ms, Mrs, Dr, Prof, etc):____________________

Degrees or Diplomas Obtained: _______________

Full Postal Address:____________________________________________________________________________________________________________________________
Phone(with country code): _______________________________

FAX: ____________________________

E-mail:_________________________________________________________________________________To the Treasurer, International Phototherapy Association (IPTA):
I hereby apply for membership of the International Phototherapy Association (IPTA) as: a Regular Member or  a Life Member (tick as appropriate). I understand that, as part of mymembership privileges, I will receive 4 issues of the current volume of Laser Therapy, the official journal ofthe IPTA. In due course, following acceptance of my application, I will receive my Membership Certificate
and Member’s Card. I have paid by payment option 1  2  (tick as appropriate)

1: International Money Order(can be ordered at any major bank: all fees to be paid by sender)

Money order for JPY ¥12,000/120,000* to be in favor of IPTA, and sent with this form by airmail to:IPTA Hon. Treasurer, c/o Japan Medical Laser Laboratory,
4F Shinsei Kaikan Bldg., 33-2 Shinanomachi, Shinjuku, Tokyo, Japan 160-0016*Delete inappropriate amount

2: Credit Card
Kindly complete the following information, and send preferably by FAX to +81-3-5269-1410
or by post to the IPTA Treasurer at the address as above.
Please debit my  Visa  Mastercard (tick as appropriate) by the sum of JPY ¥12,000/120,000*(American Express cards are unfortunately not currently acceptable)

Card number: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿Name as it appears on the card: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿(Month)___________ 3-digit security number _____________(Please use double digit numbers for month, e.g. March = 03, November = 11, et cetera)

Expiry date:(Year)20____________

Cardholder’s signature: _____________________________________

Date: _______________*Delete inappropriate amountFor bank transfer within Japan, please contact IPTA Treasurer, c/o Japan Medical Laser Laboratory:
Phone: 03-5269-1403, Fax: 03-5269-1410, E-mail: sec@jmll.co.jp