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1 Group Membership Application Hospital/Institution Name Address City State/Province Zip/Postal Code Contact Name Title Phone Members All new members and existing members who are renewing* their membership must complete and attach a separate member profile. Submit all member profiles with this form (If you have more than 5 people participating in the group membership program, please put additional names on a separate sheet of paper and be sure that each person fills our a separate member profile.) Please te: Group memberships are available to new AND renewing members. In order to be eligible for the discounted rate, there MUST be at least five participants. Additionally, only one payment will be accepted (for example: ONE check or credit card payment of $660 for a group of 5 people). Method of Payment Check or Money Order Payable to VISA MC AMEX Card Number Exp. Date Submit Application, Member Profiles and Payment to: Phone: Fax: Cardholder s Name Signature x $173 (10% discount per member) = $ Total Enclosed: $ This offer cannot be combined with any other offers, is not transferable and is subject to change without notice. Available to US and Canada members only. Questions? Please call us at ( Canada) or *All people who participate in the group membership program (both new and existing members) will have the same membership expiration date.

2 Home Phone Work Phone Position (e.g.,, Dir, Etc.) t Working and/or OTC Role Regarding Medication and/or Role in Purchasing Equipment and/

3 Home Phone Work Phone Position (e.g.,, Dir, Etc.) t Working and/or OTC Role Regarding Medication and/or Role in Purchasing Equipment and/

4 Home Phone Work Phone Position (e.g.,, Dir, Etc.) t Working and/or OTC Role Regarding Medication and/or Role in Purchasing Equipment and/

5 Home Phone Work Phone Position (e.g.,, Dir, Etc.) t Working and/or OTC Role Regarding Medication and/or Role in Purchasing Equipment and/

6 Home Phone Work Phone Position (e.g.,, Dir, Etc.) t Working and/or OTC Role Regarding Medication and/or Role in Purchasing Equipment and/

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