Industry Council Application Company InformationCompany Name(Required) Website(Required) Logo(Required)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.Logo (Print)Accepted file types: eps, pdf, Max. file size: 2 MB.Please upload the vector version of your logo (in EPS or PDF format).HiddenCouncil Representative InformationCouncil 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) PhoneHiddenBenefitsComplimentary Memberships(Required)First NameLast NameEmailChapter of Interest Add RemoveFive (5) complimentary individual At Large memberships for Women in HealthcareAdditional Discounted MembershipsFirst NameLast NameEmailChapter of Interest Add RemoveAdditional Women in Healthcare memberships at a discounted rate. National will reach out to the Council POC for additional details. HiddenBilling InformationBilling Contact First Last Billing Contact Email Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.