MEMBERSHIP APPLICATION & AGREEMENT
YES, I want to join the US Medicare PH campaign
I pledge to write and persuade the U.S. president, my two senators and Congress Member to help achieve the goals of US MEDICARE PH to extend Medicare coverage in the Philippines, to improve retirement opportunities and to protect the interests of American retirees and dependents in the Philippines.
To the best of my abilities, I will volunteer to campaign and recruit friends, family members and business associates. As a “US Medicare PH” member, I will receive:
• Membership card & gift items like lapel pins, scarfs, ties, T-Shirts, etc.
• Action Alerts and regular updates by e-mail or newsletters
• Progress reports on the quality of health care in the Philippines
• Retirement opportunities in the Philippines
• Professional advocacy representation in Washington DC by a registered lobbyist
CLASS of MEMBERSHIP applied for with annual dues and additional benefits:
• __ FOUNDING Member $500.00 (Founder or Partner with web link!)
• __ CHARTER Member $100.00 (qualifies as elected Board Director or Officer) with $50 RENEWAL
• __ REGULAR Member $50.00 (voter to elect Board of Directors) $50 RENEWAL
• __“FRIEND” Member $ 20.00 ( donation only. No voting privileges)
INDIVIDUAL MEMBER’S INFORMATION: (Please cut, paste, fill-out & e-mail)
Last Name: ____________________________ (PRINT)
First Name: ____________________________M.I. _____
Referred by: _______________________
US or PH Home Address: __________________________________________
City: __________________________ State: _______ Zip: _____________
Home/Work Phone: ________________________Cell: _________________
Optional Info: Date of Birth: M______________________/D_______/Y_________
If Filipino origin, please indicate Home Province: _________________________
Signature: __________________________ Date: _______________
Pay your dues/sponsorships securely with Debit or Credit Card with PayPal:
1) Log on www.PayPal.com
2) Enter YOUR personal e-mail address
3) Choose pay by credit card (You are not charged any FEE)
4) Enter pay to "firstname.lastname@example.org"
5) Enter amount: $500, $100, $50 etc.
6) A receipt is automatically sent to your e-mail for the approved transaction.
THANK YOU FOR PAYING YOUR DUES & SPONSORSHIP BY CREDIT CARD!
Important Tax Information:
US Medicare PH, Inc. is intended as a 501(c)4 organization. It is a non-profit membership and advocacy corporation registered in the State of Virginia. Membership dues may be tax deductible as “Dues and memberships.” Contributions to US Medicare PH may be tax deductible as part of your “Advertising” expense related to your business or trade. CONSULT your tax advisor as amounts may vary depending on your situation. It is NOT tax-deductible as “Gifts or Donations” to a charity.
See News - Page 3
1825 Great Falls St.
Falls Church, Virginia 22101
Phone: 1 202 246-1998
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