International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA Email [email protected]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: [email protected]Ph. +1-860-259-1000 Fax: +1-860-259-1030
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CORPORATE MEMBERSHIP APPLICATION - International Society for Clinical Densitometry ... · 2016-12-20 · International Society for Clinical Densitometry 955 South Main Street, Bldg.
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International Society for Clinical Densitometry 955 South Main Street, Bldg. C, Middletown, CT 06457 5153 USA
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: ______________________________________