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INDIVIDUAL MEMBERSHIP FORM STUDENT MEMBER - $60 PROFESSIONAL MEMBER - $195 (Please attach a business card or provide the following information)

 Mr.  Ms.  Dr. ________ Name: ______________________________________________ Title: _______________________________________________ Organization: _________________________________________ Mailing Address Type:  Home  Business Address: ____________________________________________ City: _______________________________________________ State/Province: _______________________________________ Zip: ______________________ Country: __________________ Phone: ______________________ Fax: ___________________ E-mail: ______________________________________________ 

The Global Health Council is a registered 501(c)(3) not-for-profit organization. Contributions to the Council above the basic membership level are tax deductible to the extent provided by law.

PAYMENT: Dues: $______________ Additional Contribution: $______________ TOTAL: $______________ Please send payment in U.S. dollars with a check or money order drawn on a U.S. bank or charge to: Visa M/C Amex Card Number: ______________________________________________________ Exp. Date: __________________Cardholder: _____________________________ Billing Address: _____________________________________________________ Signature: __________________________________________________________

Please return this form and payment to: Global Health Council 1111 19th Street NW., Ste 1120 Washington, DC 20036 Fax: (202)-747-2836

Individual Membership