I request membership in the International Otto Gross Society.

I am aware that the annual dues are currently 25 Euros or US$ 25.

Out of the By-Laws (§ 2):

The responsibility of the association is to research the social impact of the activity of the doctor, scientist, and revolutionary Otto Gross; to depict his influence on the development of intellectual history in the 20th century; and to make the results of this work publicly accessible through publications and meetings of all kinds, and through all other measures appropriate to the goals and purposes of the association. [. . .] The association pursues exclusively and directly non-profit purposes as defined by the paragraph "purposes enjoying tax privileges" of the tax policy.

Personal Information (please print):

Name:	...............................................................
First Name:	...............................................................
Academic degree, title:	...............................................................
Street address:	...............................................................
Zip code, city:	...............................................................
State/Country:	...............................................................
Phone:	...............................................................
Fax:	...............................................................
E-Mail:	...............................................................

Please fill out, sign and send to:
Anthony Templer, Grosse Hamburger Str. 15, D-10115 Berlin

Bank:
Konto 900 871 301 bei Postbank Hannover, BLZ 250 100 30