Organizational Membership Application Annual (Page 1Dues of 2) Rates
Organizations Annual Operating Budget Developing country, less than $100,000 Developing country, $100,000 to <$500,000
Dues
Individual Memberships
$0
1 full
$100
1 full 1 full
Less than $1 million
$525
$1million to < $5 million
$1,050
$5 million to < $10 million
$2,100
$10 million to <$50 million
$3,150
$50 million to <$100 million
$5,250
$100 million to <$500 million
$10,500
> $500 million
$30,000
1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all 1 full + associate benefit for all
Note: The $1,050 rate and above are eligible for free associate memberships for staff and/or students.
Organization: __________________________________________________ Mailing Address: ________________________________________________ City: _________________________________________________________ State/Province: _____________ Zip: _________ Country: _______________ Phone: ________________________________ Fax: ___________________ Website: _____________________________________________________ CEO / President: ____________________________________ Email: _____________________________________________ Main contact person for GHC Membership: Name:_______________________________________________________ Title: ________________________________________________________ Email:_____________________________ Phone:______________________
Please send payment in U.S. dollars with a check or money order drawn on a U.S. bank or charge to: Visa M/C Amex NOTE: If payment is $10,500 or greater, we cannot accept a credit card. Please return this form and dues payment to: Card Number: ______________________________________________________ Global Health Council 1111 19th Street NW., Ste 1120 Exp. Date: __________________Cardholder: _____________________________ Washington, DC 20036 Billing Address: _____________________________________________________ Signature: __________________________________________________________
1111 19th St., NW, Suite 1120 Washington, DC 20036 Tel: (202) 833-5900 Fax: (202) 747-2836 Email: membership@globalhealth.org Website: www.globalhealth.org