Become a Member

Submit your information to become a member. You can specify credit card information or be invoiced to pay at a later time.

MEMBERSHIP APPLICATION

Company:*

Address:

City:

State:

Zip Code:

Web Site Address:

http://

A/P Contact:

KEY REPRESENTATIVE

Name:*

Title:

Address:

Phone:

Fax:

E-Mail Address:*

MEMBER CLASSIFICATION

Sector Classification:*

Member Dues Category:

Please select your dues category:

$26,500. For-profit organizations with annual gross revenues of $25 million or more.

$10,500. For-profit organizations with annual gross revenues of between $10 million and $25 million.

$5,250. For-profit organizations with annual gross revenues of between $5 million and $10 million.

$2,650. For-profit organizations with annual gross revenues less than $5 million.

$5,250. Non-profit organizations with revenues of $25 million or more.

$2,650. Non-profit organizations with revenues less than $25 million.

Method of Payment:

Pay via credit card.

Be invoiced for payment.

* Upon submitting this form, you are confirming that you understand that you are obligated to pay membership dues within 30 days of receipt of the invoice and that all dues are non-refundable. An invoice will be sent to you upon approval of your application.

If you wish, you may forward this completed application via mail, facsimile, or e-mail to the eHealth Initiative at:

eHealth Initiative and Foundation
Attn: Claudia Ellison
818 Connecticut Ave., NW Suite 500
Washington, D.C. 20006
Fax: 202-429-5553
Email: claudia.ellison@ehealthinitiative.org