1 Application Details
2 Confirm Details
3 Payments

MEMBERSHIP APPLICATION FOR APHRS

Duration	Regular	Associate	Allied	Industry
1 Year	US$ 50.00	US$ 25.00	US$ 25.00	US$ 50.00
10 Years	US$ 150.00	US$ 75.00	US$ 75.00	US$ 150.00

Membership

Regular

Associate

Allied

Industry

Duration

Price

Name *

Title *

Gender *

Male

Female

Date of birth *

Company details

Name of organization *

Department / division *

Address

Country / region *

Telephone

Zip code

Facsilime

Home Address

Address *

Country / region *

Zip code

Telephone

Email *

Email address*

Secondary email address

Password *

Retype Password *

Comment

Continue

Confirm details

MEMBERSHIP

-

DURATION

-

PRICE

-

FIRST NAME

-

LAST NAME

-

TITLE

-

GENDER

-

DATE OF BIRTH

-

Company details

NAME OF ORGANIZATION

-

DEPARTMENT / DIVISION

-

ADDRESS

-

COUNTRY / REGION

-

TELEPHONE

-

ZIP CODE

-

FACSILIME

-

Home Address

ADDRESS

-

COUNTRY / REGION

-

ZIP CODE

-

TELEPHONE

-

EMAIL ADDRESS

-

SECONDARY EMAIL ADDRESS

-

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PAYMENT

Membership	Duration	Fee	Amount
	Allied 1 Year	US$ 25.00	US$ 25.00
			Total US$ 25.00

Price

US$

Discount Amount

US$

Gross Amount

US$

Coupon

MODE OF PAYMENT

Payment Method

Online Payment by Credit Card / PayPal

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Type*

Card Holder Name*

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