IAHPC ORGANIZATIONAL MEMBERSHIP APPLICATION

IAHPC ORGANIZATIONAL MEMBERSHIP APPLICATION
Join/Renew

Important Information

We value the privacy and safety of the membership information you supply us. This is a secure site and all the information that you send through this page is encrypted. The information we collect about you and the organization is only to be used by IAHPC for the purpose of this transaction. It will not be sold or shared with other individuals or organizations. If you would like to review the information that we collect from you and from the organization for this transaction, have any concerns or need to request a correction, please contact us.

SECURE ORDER FORM
Join with confidence. You are on a secure server

* = Required Field (All Dollar Amounts are in US Dollars)

1. MEMBERSHIP CATEGORY

New Member

Renewal

* Membership Type:

Membership Number or Username (if known) #:

2. MEMBERSHIP FEES

Note: The yearly amount paid by each organization is kept strictly confidential. This information will not appear in the membership directory. Only Contact Information will appear.
Fees are based on the countries per capita Gross National Income (GNI) as reported by the United Nations.

To see the list of GNI categories and the countries in each, click here

Membership benefits will be granted to 3 (three) individuals for 1-3 years of membership payment. Benefits will be granted to 5 (five) individuals when a Lifetime option is selected. This application will require you to identify those beneficiaries.
After you identify the organization’s country´s GNI category, click on the button corresponding to the category and the membership period – the system will allow clicking only one button.

INSTITUTIONAL

High

All others

Lifetime

1 Year

2 Years

130.00

200.00

340.00

220.00

500.00

300.00

1700.00

3 Years

3. CONTACT INFORMATION

*Institution- Hospice- Program Name:

*First Name:

* Last Name:

Specialty:

Affiliation:

Title:

* Email:

Confirm Email:

* Address:

Address 2:

* City:

* Prov/State:

* Country:

Postal/Zip Code:

1-3 Year Membership - Please specify the names of the 3 (three) individuals who will receive the membership benefits
Lifetime Membership - Please specify the names of the 5 (five) individuals who will receive the membership benefits

Individual #1 Name:

Individual #2 Name:

Individual #3 Name:

Individual #4 Name:

Individual #5 Name:

4. DONATE (Optional)

Help promote the development of palliative care throughout the world by donating to IAHPC. The proceedings will go to a revolving fund to support program development and membership from developing countries.

IAHPC is a charitable organization so donations to the organization are tax deductible. A copy of the IRS 501(c)3 determination letter is available upon request from IAHPC.

In addition I wish to donate:

This box should have a value or if you do not want to donate, leave the '0.00".

10.00

25.00

50.00

0.00

100.00

Other Amount:

5. IAHPC PRESS SPECIAL OFFER (Optional)

SPECIAL BOOK DISCOUNT ONLY TO IAHPC MEMBERS

PALLIATIVE CARE IN THE DEVELOPING WORLD: PRINCIPLES AND PRACTICE
Eduardo Bruera, M.D, Liliana De Lima, MHA, Roberto Wenk, M.D, William Farr, M.D
Paperback. 322 pages ISBN 0-9758525-0-7

Cost: $25.00 usd (S/H Included)

Palliative Care in the Developing World: Principles and Practice - Copies:

6. TOTAL PAYMENT

NOTE:

Please check amount entered matches your choices.

TOTAL AMONT TO BE PAID VIA CREDIT CARD $

YES I AGREE

* Do you agree to have the total amount charged to your credit card?:

7. CREDIT CARD INFORMATION

*Cardholder's Billing Address:

*Cardholder's City:

*Cardholder's State/Province:

Cardholder's Zip Code:

*Name on Card:

*Credit Card Type:

*Credit Card Number (no spaces):

*CVV:

*Expiration Month:

*Expiration Year:

*Cardholder's Email Address:

Yes

*Is a receipt required?:

Comments/Instructions:

Max 500 characters