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Industry Council Application

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Company Information

Accepted file types: png, jpg, Max. file size: 2 MB.
Please upload a high-resolution PNG or JPG of your logo. PNG with transparent background is preferred.
Accepted file types: eps, pdf, Max. file size: 2 MB.
Please upload the vector version of your logo (in EPS or PDF format).
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Council Representative Information

Council Representative Name(Required)
An appointed representative for the organization to sit on the Women in Healthcare Industry Council Board
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Benefits

Complimentary Memberships(Required)
First Name
Last Name
Email
Chapter of Interest
 
Five (5) complimentary individual At Large memberships for Women in Healthcare
Additional Discounted Memberships
First Name
Last Name
Email
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
Billing Address(Required)
Payment Type(Required)
Council Membership(Required)
Remittance and Terms(Required)
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]
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