2013 MEMBERSHIP RENEWAL/INVOICE APPLICATION
10% DISCOUNT (on/before March 31, 2013)
FEDERAL TAX ID: 58-1718541
PLEASE COMPLETE INFORMATION
NAME
TITLE
COMPANY
DEPARTMENT
ADDRESS
CITY
COUNTRY
TELEPHONE
EMAIL
ASSISTANT NAME
DEGREE
STATE
POSTAL CODE
FAX
ASSISTANT EMAIL
MEMBERSHIP CATEGORY
MEMBERSHIP IS FOR CALENDAR YEAR (JAN 1 – DEC 31, 2013). PAYMENT MUST ACCOMPANY APPLICATION
LIFETIME MEMBERSHIP
REGULAR
FULL PAYMENT (on/after April 1, 2013)
10% DISCOUNT (on/before Mar 31, 2013)
4 INSTALLMENTS (on/before Mar 31, 2013)
4 INSTALLMENTS (on/after April 1, 2013)
3 INSTALLMENTS (on/before Mar 31, 2013)
3 INSTALLMENTS (on/after April 1, 2013)
(Year 1
ASSOCIATE
FULL PAYMENT (on/after April 1, 2013)
10% DISCOUNT (on/before Mar 31, 2013)
4 INSTALLMENTS (on/before Mar 31, 2013)
4 INSTALLMENTS (on/after April 1, 2013)
3 INSTALLMENTS (on/before Mar 31, 2013)
3 INSTALLMENTS (on/after April 1, 2013)
$2,500
$2,250
$ 562.50
$ 625
$ 750
$ 834
Year 2
Year 3
Year 4
$2,000
$1,800
$ 450
$ 500
$ 600
$ 667
)
ANNUAL MEMBERSHIP
ONE YEAR (2013)
TWO YEARS (2013/14)
Regular: (MD (Practicing Healthcare Professional))
$180
$360
10% discount $162
10% discount $324
THREE YEARS (2013/14/15)
$540
10% discount $486
Associate: (MD (Non-Practicing) and Other Allied Healthcare Professional)
$150
$300
10% discount $135
10% discount $270
$450
10% discount $405
Student and Retiree: (graduate/professional school), Residents/Fellows)
$75
$150
10% discount $67.50
10% discount $135
$225
10% discount $202.50
METHOD OF PAYMENT
Enclosed is a
PERSONAL CHECK
INSTITUTIONAL/COMPANY CHECK
MONEY ORDER
CHECK /MONEY ORDER NUMBER _________________________________________
SEND COMPLETED APPLICATION
(MAKE CHECK PAYABLE TO ISHIB)
MAIL:
Print and mail to:
ISHIB
2111 Wilson Boulevard, Suite 700
Arlington, VA 22201
FOR OFFICIAL USE ONLY DATE RECEIVED_____________________________
CHECK/MONEY ORDER
.
2111 WILSON BOULEVARD, STE 700 • ARLINGTON, VA 22201 USA • PHONE: 703.351.5023 • FAX: 703.351.9292 • WWW.ISHIB.ORG