Enrollment
Home Up Enrollment Certificate

 

IPHC Heritage Society Enrollment

If you wish to join the IPHC Heritage Society, please complete this form.  Do NOT include credit card information on this form. If you use this form, a bill will be sent to the postal address provided below. These donations are tax deductible. If you prefer to pay online with Visa. MasterCard, American Express or Discover, then please wait until this is operational again.

Please provide the following contact information:

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Please choose from among the following:

for the 2005-2009 Quadrennium - $250
with a Lifetime Membersip - $1,000
I wish to support the IPHC Heritage Society by honoring a special person with a $250 memorial.

Select payment plan:

$250 Membership full payment 2 payments of $125 payable within two years
$1,000 Lifetime Membership full payment 4 payments of $250 payable within four years

            PRINT NAME AS IT SHOULD BE ENGRAVED:

Name

Last revised: January 26, 2011