Issuu on Google+

Organizational Membership Application Annual (Page 1Dues of 2) Rates  

Organizations Annual Operating Budget Developing country, less than $100,000 Developing country, $100,000 to <$500,000

Dues

Individual Memberships

$0

1 full

$100

1 full 1 full

Less than $1 million

$525

$1million to < $5 million

$1,050

$5 million to < $10 million

$2,100

$10 million to <$50 million

$3,150

$50 million to <$100 million

$5,250

$100 million to <$500 million

$10,500

> $500 million

$30,000

1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all

Note: The $1,050 rate and above are eligible for free associate memberships for staff and/or students.

Organization: __________________________________________________ Mailing Address: ________________________________________________ City: _________________________________________________________ State/Province: _____________ Zip: _________ Country: _______________ Phone: ________________________________ Fax: ___________________ Website: _____________________________________________________ CEO / President: ____________________________________ Email: _____________________________________________ Main contact person for GHC Membership: Name:_______________________________________________________ Title: ________________________________________________________ Email:_____________________________ Phone:______________________

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 NOTE: If payment is $10,500 or greater, we cannot accept a credit card. Please return this form and dues payment to: Card Number: ______________________________________________________ Global Health Council 1111 19th Street NW., Ste 1120 Exp. Date: __________________Cardholder: _____________________________ Washington, DC 20036 Billing Address: _____________________________________________________ Signature: __________________________________________________________

1111 19th St., NW, Suite 1120 Washington, DC 20036 Tel: (202) 833-5900  Fax: (202) 747-2836 Email: membership@globalhealth.org Website: www.globalhealth.org


Organizational Membership Form