Membership Application | Fetal Heart Society

Membership Dues

Organization Code

If you were given a code to sign up for an organization, enter it now and hit the submit button

Application Fee: $7,500.00

Your Dues Rate Type is: Institutional Platinum Sponsorship $7,500.00

Add-On Password

You must create a password that will be used by your members to join your organization. You will be given instructions at the end of the member application on what information to pass onto your members, and how they can join.

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Suffix

Title *

Informal Name

Company *

Address Line 1 *

Address Line 2

Address Line 3

City *

State

Zip Code *

Country *

Website

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Username/Password Username/Password

Please enter the Username/Password you would like to use to login to this website.

Your Username must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Username *

Password *

Confirm Password *

Additional Options

Select additional contact types to include as part of your membership:

Institutional Active Membership - $0.00

Institutional Affiliate Membership - $0.00

Payment Details

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing Fetal Heart Society to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting Fetal Heart Society, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Total Amount Due

$

Platinum Sponsorship Renewal

Membership Dues

Contact Information Contact Information

Username/Password Username/Password

Additional Options Additional Options

Payment Details Payment Details

Contact Information

Additional Options

Payment Details