Individual Membership Renewal Part 1 of 2

This form is ONLY for ONLINE PAYMENT by CREDIT / DEBIT CARDS.

*The APHN Constitution requires all members to agree and uphold the Objectives and Values of the Asia Pacific Hospice Palliative Care Network. Please click here to read the Objectives and Values.

Please note:
If you will like to pay by BANK DRAFT or CHEQUE, please fill in your renewal form HERE.

E-mail *
Name *
Title *
Gender *
Profession *
Specialty *
Which organization do you work for? *
Current Position/Title in work place *
Are there any area(s) you will like to contribute as a member? Please choose one or more of the following: *
Please specify other area(s) of contribution that is not mentioned above:
If you have selected teach/train on short-term basis, please indicate here the topics/subjects you are strong at:

Contact Numbers

Mobile no. (if you do not hold a mobile phone, please provide a contactable number): *
Office no.
Residential no.
Skype name
I have read and understand the Objectives and Values* of the Asia Pacific Hospice Palliative Care Network and agree to support and uphold them. *
I agree to have my name and email included in the Members' Registry Booklet given to all APHN members. *
Please enter the words in the box to confirm your renewal:

If you require further assistance, please contact the Secretariat at membership@aphn.org.

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