corporate membership application - international society for clinical densitometry ... ·...

International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA

Email kcallahan@iscd.org Ph. +1-860-259-1000

CORPORATE MEMBERSHIP APPLICATION

Please invoice my organization for the following level of corporate membership. ! Platinum $15,000 ! Gold $7,500 ! Silver $5,000 ! Bronze $2,500 ! Contributor $1,500

Organization: ____________________________________________________________________________________

Mailing Address: _________________________________________________________________________________

City: ___________________________________________ State/Province: ___________________________________

Zip/Postal Code: ________________________________ Country: _________________________________________

Business Phone: _________________________________ Fax: _____________________________________________

Contact Person: ___________________________________________________________________________________

Email: ___________________________________________________________________________________________

Please list the person(s) who will be utilizing the company’s individual memberships. Refer to chart above for number of individuals in your membership level. Use the additional sheet, if necessary. Last Name: _____________________________________ First Name: ______________________________________

Title: ____________________________________________________________________________________________

Mailing Address: __________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: _________________________

Home Phone: _________________________________ Cell Phone: ________________________________________

Email: ____________________________________________________________________________________________

CORPORATE MEMBERSHIP LEVELS

CORPORATE INFORMATION

MEMBERSHIP COVERAGE

Return completed form to: International Society for Clinical Densitometry

955 South Main Street, Bldg. C Middletown, CT 06457-5153 USA

Email: kcallahan@iscd.org Ph. +1-860-259-1000

Fax: +1-860-259-1030

International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA

Email kcallahan@iscd.org Ph. +1-860-259-1000

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

ADDITIONAL MEMBERSHIP COVERAGE

International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA

Email kcallahan@iscd.org Ph. +1-860-259-1000

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

Last Name: _____________________________________ First Name: _______________________________________

Title: _____________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

City: __________________________ State/Province: _________________ Zip Code: __________________________

Home Phone: _________________________________ Cell Phone: _________________________________________

Email: _____________________________________________________________________________________________

ADDITIONAL MEMBERSHIP COVERAGE