Sustaining Membership - New Hampshire Hospice and Palliative

125 Airport Road
Concord NH 03301
Phone: 603-415-4298 Fax: 603-672-4409
[email protected]
2015 Sustaining Membership Dues
Dues are effective through 12/31 of the calendar year in which they are paid.
Sustaining Members are community partners, professional colleagues and businesses having an interest in
supporting the work of hospice and palliative care at a higher level.
$250 membership fee includes the following benefits:
• NHHPCO website listing
• Subscription to NHHPCO monthly newsletter
• One complimentary pass to our Annual Fall Conference
Contact Information:
Organization/Business/ Individual Name:_________________________________________________
Address: ________________________________________________________
City: _____________________ State: _______ Zip: ______________
Phone: __________________email address_______________________________________________
Form of Payment:
Check enclosed
Credit Card ** we do not accept American Express
Please make checks payable to NHHPCO, 125 Airport Road, Concord, New Hampshire 03301 or fax with
credit card information to 603 672 4409.
Level of membership:
Individual Sustaining Member $250
I would like to add a tax deductible donation to support the work of NHHPCO
TOTAL amount enclosed $______________
Credit Card Information:
Card Number: __________________________ Exp.______/_______
Total Charge Amount: $______________________
Print name of cardholder: _________________________________________________________________
Authorized Signature:____________________________________________________Date:____________
Thank You!