Sustaining Membership Application 2004
(Individual or Corporate Application must also be completed.)

Sustaining Memberships recognize an individual or business that provides NIPHLE with extensive financial support. The current annual financial
contribution required to become a Sustaining Member is $2,400.00.
Date Name
Company/Affiliation
Phone  Fax Email
Address
City State Zip
Who from NIPHLE encouraged you to become a sustaining member?
Please indicate ways that you plan to achieve a total contribution of $2,400:

"Cash" Donation to NIPHLE

Sponsorship of Fall Conference Event

Sponsorship of Spring Conference Event

Scholarship Contribution

Annual Dues

Paid Table Top Display (in lieu of one free Table Top Display)

Paid Conference Registration
(in lieu of one free Conference Registration)

Other
TOTAL:
 Annual membership status runs from September to September with new members joining after April 30 automatically in membership status for the following NIPHLE year.
Check enclosed Bill My: Visa Master Card American Express

Account Number: Expiration Date:

Signature: _________________________________________________

Please make checks payable to NIPHLE and mail with application to:
NIPHLE - 6902 Lyle Street - Lanham, MD 20706-3454
301-459-9105 • FAX 301-459-4925
niphle@erols.com
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