corporate membership application - international society for clinical densitometry ... ·...
TRANSCRIPT
International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA
Email [email protected] Ph. +1-860-259-1000
CORPORATE MEMBERSHIP APPLICATION
Please invoice my organization for the following level of corporate membership. ! Platinum $15,000 ! Gold $7,500 ! Silver $5,000 ! Bronze $2,500 ! Contributor $1,500
Organization: ____________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
City: ___________________________________________ State/Province: ___________________________________
Zip/Postal Code: ________________________________ Country: _________________________________________
Business Phone: _________________________________ Fax: _____________________________________________
Contact Person: ___________________________________________________________________________________
Email: ___________________________________________________________________________________________
Please list the person(s) who will be utilizing the company’s individual memberships. Refer to chart above for number of individuals in your membership level. Use the additional sheet, if necessary. Last Name: _____________________________________ First Name: ______________________________________
Title: ____________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: _________________________
Home Phone: _________________________________ Cell Phone: ________________________________________
Email: ____________________________________________________________________________________________
CORPORATE MEMBERSHIP LEVELS
CORPORATE INFORMATION
MEMBERSHIP COVERAGE
Return completed form to: International Society for Clinical Densitometry
955 South Main Street, Bldg. C Middletown, CT 06457-5153 USA
Email: [email protected] Ph. +1-860-259-1000
Fax: +1-860-259-1030
International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA
Email [email protected] Ph. +1-860-259-1000
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
ADDITIONAL MEMBERSHIP COVERAGE
International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA
Email [email protected] Ph. +1-860-259-1000
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
Last Name: _____________________________________ First Name: _______________________________________
Title: _____________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: __________________________ State/Province: _________________ Zip Code: __________________________
Home Phone: _________________________________ Cell Phone: _________________________________________
Email: _____________________________________________________________________________________________
ADDITIONAL MEMBERSHIP COVERAGE