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Organization Enrollment Form

I am a: new member  |  renewing member  
  Enter Member ID#
  
Membership Category (choose one - required)

Annual Budget under $500,000:
      -- Dues $250 --

Annual Budget $500,000 to < $1 million:
      -- Dues $500 --

Annual Budget $1 million to < $5 million:
      -- Dues $1,000 --

Annual Budget $5 million to < $10 million:
      -- Dues $2,000 --

Annual Budget $10 million to < $50 million:
      -- Dues $3,000 --

Annual Budget $50 million to < $100 million:
      -- Dues $5,000 --

Annual Budget $100 million to < $500 million:
      -- Dues $10,000 --

Annual Budget $500 million and above:
      -- Dues $25,000 --


Contact Information (fields with a * are required)

Mr.   Ms.   Dr.  
Name: *
     
First MI Last
Title:
(if applicable)
Organization: *
Classification: *
Postal Address: *
City: *
State/Province:
Zip/Postal Code:
Country: *
Work Phone: *
Fax:
E-mail: *

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Questions? Please contact the Membership Department at (802) 649-1340 or membership@globalhealth.org.