INDUSTRY PARTNER APPLICATION
COMPLETE ALL INFORMATION
Organization Name
Address
City
State
Zip
Tel.
Fax
Website
Representative #1
(Main Contact Person)
Name
Title
Department
E-mail
Tel.
Fax
Representative #2
Name
Title
Department
E-mail
Tel.
Fax
Representative #3
Name
Title
Department
E-mail
Tel.
Fax
Representative #4
Name
Title
Department
E-mail
Tel.
Fax
PAYMENT INFORMATION
PARTNERSHIP LEVEL
PLATINUM $15,000.00 (4 representatives)
SILVER $7,500.00 (2 representatives)
I hereby authorize APHSA to charge my:
MasterCard
VISA
American Express
Check (Make payable to APHSA)
Wire Transfer (Please send details)
Card Number
Security Code
Name on Card
Expiration Date
By clicking the submit button below you agree to pay APHSA the amount for the membership you selected in full, which will be charged to your credit card
in the following billing cycle.
APHSA Industry Partner Application - V1/2013
1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036 | T 202.682.0100 | F 202.289.6555 | www.aphsa.org | memberservice@aphsa.org
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