Industry Council Application - Women in Healthcare

Council Representative Information

Council Representative Name(Required)

First Last

An appointed representative for the organization to sit on the Women in Healthcare Industry Council Board

Title(Required)

Email(Required)

Phone

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Benefits

Complimentary Memberships(Required)

First Name

Last Name

Chapter of Interest

Five (5) complimentary individual At Large memberships for Women in Healthcare

Additional Discounted Memberships

First Name

Last Name

Chapter of Interest

Additional Women in Healthcare memberships at a discounted rate. National will reach out to the Council POC for additional details.

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Billing Information

Billing Contact

First Last

Billing Contact Email

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tax ID/EIN/SSN(Required)

Payment Type(Required)

Check

Credit Card

ACH

Council Membership(Required)

Year 1

Year 2

Total

Remittance and Terms(Required)

I have read the below terms and remittance details.

Effective on the date of payment, my organization will assume one chair seat on the Women in Healthcare Industry Council. This is a 2 year term. My organization understands the financial and time commitment of this position.

Credit card and ACH payments will be reminted via a payment link that will be provided to you in 5-7 business days. Payment is due within 30 days of

Please remit checks to the following address:
Women in Healthcare, Inc.
ATTN: Billing, Ashley Schmidt
8918 Mount Patapsco Ct.
Ellicott City, MD 21042

Any additional questions should be directed to [email protected]

I am not a robot.

Company Information

Council Representative Information

Benefits

Billing Information