CORPORATE MEMBERSHIP FORM

APPLICATION DATE:

COMPANY NAME:

ADDRESS: CITY:

STATE: ZIP CODE:

PHONE NUMBER: FAX NUMBER:

CONTACT NAME FOR EVENT NOTICES: EMAIL ADDRESS:

CONTACT NAME FOR MEMBERSHIP: EMAIL ADDRESS:

URL:

MEMBERSHIP LEVELS: (PLEASE CIRCLE ONE)

DIAMOND $20,000 EMERALD $15,000 PLATINUM $10,000 GOLD $5,000 SILVER $2,500

PAYMENTS: (PLEASE CIRCLE ONE)

PLEASE SEND A CHECK OR PAY BY CREDIT CARD (SEE BELOW)

CREDIT CARD TYPE: (CIRCLE ONE) VISA MASTERCARD DISCOVER AMERICAN EXPRESS

CARDHOLDER NAME:

CREDIT CARD NUMBER:

EXPIRATION DATE:

SECURITY CODE:

SIGNATURE:

CREDIT CARD PROCESSING PHONE LINE: 1-855-605-PAID (7243)

Maryland and District of Columbia Society of Clinical Oncology

X 501(c)6

550M Ritchie Highway, #271

Severna Park, MD 21146

5 2 1 8 3 3 7 2 1

8/1/017