Membership Application - ASSOCIATE


Individuals that are employed by an oncology hematology practice and are represented by one ACTIVE member. (Example: Administrator is the Active member then the billing manager, nurse and/or purchasing manager would be the Associate member). There is no limit to the number of associate members per practice.

Annual Dues:

Applicant Information
First Name
Last Name
Title/Position
Degree
Email Address
Date of Birth
Gender

Practice Information
Active Member:
Practice Name
Address

City	State Zip
Phone
Fax

ACKNOWLEDGEMENT
As a member of the Premier Oncology Hematology Society I agree that my practice will be represented at not less than two meetings or events in a year (the annual conference counts as one meeting). I further understand that failure to comply with these membership requirements may result in the revocation of my practice membership. I also understand under these conditions, membership dues are non-refundable

- denotes required fields

Applicant Information