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 of the Asia Pacific Hospice Palliative Care Network. Please click here to read the Objectives.

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* 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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