Dues Form

 

Please note that this form is not electronic and no information is ever sent from your browser across the internet. This form is designed to facilitate the creation of a correct invoice for membership in ISRHML. This form can then be printed on your printer and mailed to:

ISRHML
Frank R. Greer
Meriter Hospital-6C
202 South Park Street
Madison, WI
53715
USA

or faxed to:
Frank R. Greer
+1 (608) 267 6377

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Date:...............................................................................................................................................
       
Name:.............................................................................................................................................
       
Institution:.......................................................................................................................................
       
Telephone:.....................................................................................................................................
       
Fax:................................................................................................................................................
       
E-mail address:..............................................................................................................................
_______________________________________________________________________________________
       
Type of Membership:
  • Full (USD $75)
O  

  • Associate (USD $30)
 O  
       
Amout due:....................................................................................................................................
       
Type of payment:
  • Check/Cheque (preferred for USA )
 O  
 
  • Credit card – Visa or MasterCard (preferred for non-USA)
O  
_______________________________________________________________________________________
       
Type of credit card:...........................................................................................................................
       
Credit card number:.........................................................................................................................
       
Credit card expiery date:..................................................................................................................
       
Name on credit card:........................................................................................................................
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