125 Airport Road Concord NH 03301 Phone: 603-415-4298 Fax: 603-672-4409 [email protected] www.nhhpco.org 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: MasterCard Visa Discover Card Number: __________________________ Exp.______/_______ Total Charge Amount: $______________________ Print name of cardholder: _________________________________________________________________ Authorized Signature:____________________________________________________Date:____________ ________________________________________________________________________________________ Thank You!