Industry Council Application Company Name*Website* Council Representative Name* First Last An appointed representative for the organization to sit on the Women in Healthcare Industry Council Board Title*Email* PhoneLogo*Accepted file types: png, jpg.Please upload a high-resolution PNG or JPG of your logo. PNG with transparent background is preferred.Logo (Print)Accepted file types: eps, pdf.Please upload the vector version of your logo (in EPS or PDF format).Complimentary Memberships*Five (5) complimentary individual At Large memberships for Women in HealthcareFirst NameLast NameEmail Additional Discounted MembershipsAdditional Women in Healthcare memberships at a discounted rate. National will reach out to the Council POC for additional details. First NameLast NameEmailChapter of Interest Engagement Effort of Interest: Book Club Selection and Moderator Podcast Interview Newsletter Article Presentation of a content topic Instagram/Social Media Stories take over Representation of one or more corporate members at one WIH engagement effort a year. Please Indicate which efforts would be of interest to your organization. National will follow up with further details. Billing Contact First Last Council Membership*Year 1Year 2Total $0.00 Payment Method*Credit/Debit CardCheckCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Please mail checks to: Women in Healthcare Attn: Membership/Sponsorship 6996 Deep Cup Columbia, MD 21045
