Organisational Membership

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Email Address*

Region:*

If your region is not found in the list above, please apply for individual membership.

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Region or Country

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Membership level

Based on the region selected for your mailing address, your annual subscription

Price:

Based on the region selected for your mailing address, your annual subscription

Price:

Based on the region selected for your mailing address, your annual subscription

Price:

Based on the region selected for your mailing address, your annual subscription

Price:

We wish to apply for membership and and pay a subscription for*

Name of Organisation*

Particulars of Signatory / Contact Person

Title*

Gender

Name*

First Last

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 would like to contribute as a member? Please choose one or more of the following:*

Please indicate here other area(s) your organisation would 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

Address

Street / Road Name Address Line 2 City State/ Province ZIP / Postal Code Sector

Contact Numbers

Office no.*

Mobile no.*

Fax no.

Your organisation's website

Consent*

I have read and understood the Objectives and Values* of the Asia Pacific Hospice Palliative Care Network and agree to support and uphold them.

Consent*

I have read and understood the Objectives and Values* of the Asia Pacific Hospice Palliative Care Network and agree to support and uphold them.
I understand that APHN’s membership is based on the calendar year, January 1 through December 31.

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).*

Yes
No

Payment Options

Name of person filling out this form:*

First Last

Please select one of these options for payment of the membership fee:*

Payment via Credit/Debit

PLEASE READ: Auto-Renewal Information
Your subscription will auto-renew yearly on 1 January. If you do not wish to be automatically billed on the 1 of Jan every year, please email us at support@aphn.org

Payment via Cheque

Please make cheque payable to “Asia Pacific Hospice Palliative Care Network”. Kindly mail the completed form to us at the address below:

APHN Secretariat
c/o Division of Supportive & Palliative Care
National Cancer Centre Singapore
11 Hospital Crescent
Singapore 169610

Total

$0.00

Please note that The APHN Constitution Article 6.2 states that “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.”

Organisational Membership

Particulars of Signatory / Contact Person

Mailing Address

Contact Numbers

Payment Options

Payment via Credit/Debit

Payment via Cheque

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