ISPOR SA Chapter Membership Application Form

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Please note that consent is required to complete this form.

Registration Type

*Please note that all student memberships will expire after one year. Students must reapply for exemptionn after the year has passed (with proof of registration) or full membership rates apply.

* Non-profit memberships will expire after one year. Members must reapply for exemption with proof of non-profit registration.

Invoicing Options

Funding Type

Billing Details of Person/Company/Institution Responsible for Bill

This address will be used to issue Membership Invoices

Full names of colleagues who must be included on the invoice:

Total Number of Colleagues on Invoice

Industry Membership

Government/Academia Membership

Total

Main Applicant Information

TitleFirst NameLast Name

Upload Proof of Registration as Full-time Student/ as a Non-Profit Entity.

Relevant, Highest Qualifications

Example: MSc (Health Economics)

Current Institution/Organisation/Company

Organisation Type

Your Current Field of Work/Study

Mobile Number

Telephone Number (Office)

E-mail Address

example@example.com. Please ensure this is correct as this address will be used to forward your proforma invoice

Country

Province

City

Billing Options

Is this your first time registering as an ISPOR SA Member?

Why did you join ISPOR SA?

In the last two years, which ISPOR SA offerings produced the most value to you?

Do you have any feedback for ISPOR SA such as topics or opportunities to consider/areas for improvement?

Would you like to become more involved in ISPOR SA?

Other

www.isporsa.co.za