Phone: 603-415-4298 Fax: 603-672-4409
2018 Palliative Care Provider Membership Dues Invoice
Palliative Care Provider Members are any public or private agency, entity, center, institution or part thereof, providing palliative care and recognized by a healthcare institution as a distinct palliative care program. Dues are effective through 12/31 of the calendar year in which they are paid.
Palliative Care Provider Membership dues: Total = _$ 500_
Enhance your membership by supporting NHHPCO as a Patron Palliative Care Provider Member:
Patron Palliative Care Provider Members will receive all benefits of basic membership, plus:
- Listing on NHHPCO website as a Patron Palliative Care Member
- Two complimentary registrations to the Annual Fall Conference
Patron Palliative Care Provider Membership dues: Total = _$1,000_
PLEASE MAIL COMPLETED FORM AND PAYMENT TO:
New Hampshire Hospice and Palliative Care Organization (NHHPCO)
125 Airport Road, Concord, New Hampshire 03301
Attention: Janice McDermott, Executive Director
Phone: 1-603-415-4298 | Fax: 603-672-4409 |
Palliative Care Program Contact Information:
Organization Full Title: ______
Address: ______
City: ______State: ______Zip: ______
Phone: ______Fax:______
Website address______
Level of membership: ?Palliative Care Provider Membership - $500
?Patron Palliative Care Provider Member- $1,000
Form of Payment: ?Check enclosed ?Credit card* we do not accept American Express
Make checks payable to NHHPCO,125 Airport Road, Concord, New Hampshire 03301
Credit Card Information: ?MasterCard?Visa ? Discover (we cannot accept American Express)
Card Number ______/______/______/_____ Exp._____/_____ 3 digit security code ______
Please Complete All Information Requested:
Total Charge Amount: $______
Print name of cardholder: ______
Address of Cardholder:
Street Address:______City/State/Zip:______
Authorized Signature: ______Date:______
Please help us keep our website and mailing lists current. Staff Members listed below will receive the weekly Hospice NewsNetwork publication as well as invitations to education events and peer network group meetings.
NameEmail
Administrator: ______
Medical Director: ______
Nurse Manager: ______
Social Work: ______
Chaplain: ______
Other: ______
Other: _______
THANK YOU!