Membership List Rental Application & Security Agreement

The Heart Rhythm Society (HRS) allows the use of its membership mailing list for the express purpose of supporting our mission to improve the care of patients by promoting research, education and optimal health care policies.

This form is to be used for requesting the HRS membership mailing list for the express purpose of promoting educational products or materials. If you intend to use the list for any other purpose, including marketing an educational event, please visit to review alternative list rental options.

Membership Lists:

Full List $1,200 (N= 5,000+)

Partial List $800

Physicians (N= 3,000+)

Allied Health Professionals (N= 1,000+)

USA members only (circle: Physicians, Allied Health Professionals or both)

Please send your completed application to the contact information below and allow up to 10 business days for approval and processing. Upon approval, the list will be e-mailed to the address provided below. The list is available in Excel format to rent for one-time use only and may not be entered into a database.

To apply, please submit:

  • Copy of the material to be mailed
  • Rental Application (Page 1 of this document)
  • Signed Security Agreement (Page 2 of this document)
  • Payment

Heart Rhythm Society, Membership Department

1325 G St, NW, Ste 400, Washington, DC 20005

Direct: 202-464-3470, Fax: 202-464-3401

Contact Name: ______Company Name: ______

Phone: ______Email Address: ______

Address: ______

City: ______State: ______Zip: ______

Type of Payment (choose one)CheckMasterCardVISAAMEX

Credit Card #______Expiration Date: ______

Amount $______Cardholder Name (please print): ______

Note: Heart Rhythm Society does not accept Purchase Orders (POs).

LIST RENTAL SECURITY AGREEMENT

Between

Heart Rhythm Society Company Name: ______

1325 G St NW, Ste 400 andAddress: ______

Washington, DC20005 ______

Attn: Membership Department ______

  1. Mailing addresses furnished by the Heart Rhythm Society are for one time rental use only by the party named above and may not be sold, provided, copied, duplicated, transferred to any computer file or otherwise reproduced. This list data is "seeded" with identifying names. Unauthorized appearance in the mail of any such name constitutes evidence of complete reuse of the list. In the event of such unauthorized use, the undersigned will be held responsible to pay ten times the established rental price for the list originally delivered. Legal action may be taken due to violation of copyright laws.
  1. The list should be inspected prior to its use. It is understood that use of the list constitutes satisfactory completion of the renter’s instructions.
  1. In the event of any error or omission on the part of Heart Rhythm Society, the Society may elect to supply an updated copy of the list at no charge to the renter. It is understood that Heart Rhythm Society shall not be liable for any special or exemplary damages.
  1. Any additional work caused by errors, omissions or ambiguities in the client's instructions on the Rental Application will be billed to the client at Heart Rhythm Society's standard rate.
  1. The list will be e-mailed only after this form is signed by the party named above and returned to Heart Rhythm Society with a completed Rental Application, payment and a copy of the materials that will be mailed to the list. The Heart Rhythm Society reserves the right to refuse to rent the list at its discretion to applicants that are deemed unsuitable and agrees to refund the full payment amount in the event of such refusal.

I agree to the above terms and conditions:

Authorized SignatureName (Please Print)Date

Contact name:

Phone: E-mail:

1325 G St NW Ste 400|Washington, DC 20005 | USA | Phone: 202-464-3400 | Fax: 202-464-3401 | |