GHEC Institutional Student Forum (ISF)
Membership Application Form
(January 1 - December 31, 2006)

  
 
ISF Membership: $400 USD

 
 
Institutional Student Forum Memberships carry four (4) individual memberships and unlimited student memberships. Please indicate the names and address of all four individual members in the spaces below. If all have not been selected at this time, the additional names may be submitted to the GHEC Secretariat at a later date. Students register seperately using the Student Online Application.
 
 


Notes about E-mail and the Listserv:

Be sure to include an e-mail address for each member who has one. The GHEC Listserv is a very useful tool for
communication among members, and a way for the Secretariat to send out announcements and other timely items to all members.

Your email address will be *automatically* added to the GHEC Listserve unless you indicate you do *not* want to be included.E-mail addresses will not be provided to any other organization.

 
 
Name:
Phone:
Title:
 		Fax:
University or Other Affiliation:
Department:
Mailing Address:
City:
 		State: Zip:
E-mail Address:
 
_____ I do not want to be added to the GHEC Listserv
I will act as our membership's designated "Leader" and should be the recipient of all GHEC renewal notices. ___Yes | ___No (Please check one)
 
 
Name:
Phone:
Title:
 		Fax:
University or Other Affiliation:
Department:
Mailing Address:
City:
 		State: Zip:
E-mail Address:
 
_____ I do not want to be added to the GHEC Listserv
I will act as our membership's designated "Leader" and should be the recipient of all GHEC renewal notices. ___Yes | ___No (Please check one)
 
 
Name:
Phone:
Title:
 		Fax:
University or Other Affiliation:
Department:
Mailing Address:
City:
 		State: Zip:
E-mail Address:
 
_____ I do not want to be added to the GHEC Listserv
I will act as our membership's designated "Leader" and should be the recipient of all GHEC renewal notices. ___Yes | ___No (Please check one)
 
 
Name:
Phone:
Title:
 		Fax:
University or Other Affiliation:
Department:
Mailing Address:
City:
 		State: Zip:
E-mail Address:
 
_____ I do not want to be added to the GHEC Listserv
I will act as our membership's designated "Leader" and should be the recipient of all GHEC renewal notices. ___Yes | ___No (Please check one)
 
     
  ** Where a Membership Leader is not indicated, the position will be designated to the first person listed on the form.  
   
Person completing this form:		  
 
Name:
  		Phone:
 
 


Please make checks *payable in USD* and send to:
GHEC Secretariat
305 West Broadway, #332
New York, NY 10013

Please enclose this form with your payment

Our Federal Tax ID# is: 94-3175750

Questions about dues should be directed to: info@globlahealth-ec.org
 or by phone: (646) 831-3220, fax: (646) 839-2707

  
     
copyright 2005 Global Health Education Consortium