Application for Organisational Membership

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

E-mail *
Username *
We wish to apply for membership and would like to pay subscription for *
Our annual subscription fee is *
Name of Organisation *

Particulars of Signatory / Contact Person

Title *
Gender *
Name *
Profession *
Specialty *
Designation in organisation *
How did your organisation come to know about APHN? *
What does your organisation hope to gain as a member? *
Are there any area(s) your organisation will like to contribute as a member? Please choose one or more of the following: *
Please indicate here other area(s) your organisation will like to contribute that is not mentioned above:
Number of years providing palliative care / hospice and related services: *
Average number of patients seen per month (for medical-based services, e.g. inpatient unit, hospice home care service, outpatient clinic, etc.): *
Average number of clients served per month (for non-medical-based services, e.g. counselling, support groups, training and education, etc.) *
Please indicate the type of service(s) provided: *
Please indicate here other type of service(s) not listed above:

Mailing Address

Department
House / Block No.
Unit No.
Street / Road Name
City *
State / Province
Postal Code / Zip Code
Country *

Contact Numbers

Office no. *
Mobile no. (if you do not hold a mobile phone, please provide a contactable number) *
Fax no.
Skype name
Your organisation's website
We have read and understand the Objectives* of the Asia Pacific Hospice Palliative Care Network and agree to support and uphold them. *
We agree to have our name and contact details included in the Members' Registry Booklet given to all APHN members. *
We would like to have our organisation listed on the online Directory accessible to members of the public. (If "Yes", please provide full address and essential contact numbers). *

Payment Options

Please select one of these options for payment of the membership fee: *
  • If you are paying by bank draft, please ask your bank to convert from US dollars to Singapore dollars before buying the draft.
  • Please make bank draft or cheque payable to "Asia Pacific Hospice Palliative Care Network".

We declare that the information given in this application are true and correct.

Name of person filling out this form: *
Please enter the words in the box to confirm your application:

If you need further assistance or clarification, please contact the Secretariat at membership@aphn.org

Please note:
After you have submitted the completed form, you will receive an email with the information you have submitted as a confirmation that your form was submitted successfully. If you have selected payment through PayPal, you will receive an email from the Secretariat providing the link to pay through PayPal after your membership application is approved.

The email reply will take around 14 working days.

The application for membership of the Association shall be made in writing and shall be considered by the Council which shall have the absolute discretion to decide upon acceptance or rejection. No reason will be given for its decision, which shall be final and not be questioned in any court of law. (Constitution, article 6.2). More on membership rights, privileges and others, please refer to the APHN Constitution articles 6 to 9.

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