Membership Application
For Membership Year : July 1, 2008 to June 30, 2009
Organization Name:
___________________________________________________________Year Founded:
________________Org/Company Representative:
__________________________________________________________Title:
_____________________________________________________________________________Address:
_________________________________________________________________________City / Province:
_______________________________________________Postcode:
____________________________Phone:
_________________________________Fax:
______________________________________E-mail:
_________________________________________________________________Web Site: - _________________________________________________________
Healthcare Category: please choose one of the following:
Health Related Biotechnology
Healthcare Services
Health Informatics
Medical Devices
Pharmaceuticals
Nutraceuticals
Health Related Association
Educational Institution
Related Services
Professional Services
Membership Category Selection
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Please select the desired category of membership.
Please also complete the back of this form to ensure your company is properly listed in the Directory
.FULL MEMBERSHIP
Please indicate the number of personnel employed by your firm in the health sector:
11-49 Employees -
$500.002 - 10 Employees - $200.00
Individual - $100.00
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STUDENT MEMBERSHIP $ 25.00
Institution___________________________Current
Year of Study_______________Program ___________________________Student ID Number _________________
MEMBERSHIP DUES ENCLOSED
$________________Please submit your completed form, with payment made payable to AHIA, to the AHIA Office at:
Box 3345, Fort Saskatchewan, AB T8L 2T3
Company Profile
Please provide a brief profile of your organization: