MEMBERSHIP APPLICATION & AGREEMENT FORM
YES, I want to join the US Medicare PH campaign
I pledge to write and persuade President Obama, my two US Senators and Congress Member to help achieve the goals of US MEDICARE PH: extending Medicare coverage in the Philippines, improving retirement opportunities and protecting the interests of US Retirees in the Philippines.
To the best of my abilities, I will volunteer for the campaign, and recruit friends, family members and business associates.
As a “US Medicare PH” member, I will receive:
• Membership card & gift items like 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 and representation in Washington DC by a registered lobbyist
CLASS of MEMBERSHIP Applied:
Initial Membership Annual Dues & Additional Benefits
• __ Founding Member $500.00 (recognized in Founders/Officers' web page)
• __ Charter Member $100.00 (qualifies for BOD and Officer positions) $50 RENEWAL
• __ Regular Member $ 50.00 (voting rights to elect Board of Directors) $50 RENEWAL
• __“Friends” Member $ 20.00 ( donation only. No voting privileges)
INDIVIDUAL MEMBER’S INFORMATION: (Please cut, paste, fill-out & e-mail)
Last Name: ____________________________
First Name: ____________________________M.I. _____
US Home Address: ___________________________________________________________
City: __________________________ State: _______ Zip: _____________
Home/Work Phone: ________________________Cell: _________________
Optional Info: Date of Birth: M______________________/D_______/Y_________
If Filipino origin, please indicate Home Province: _________________________
Referred by: _______________________
1) Log on www.PayPal.com
2) Enter YOUR personal e-mail address
3) Enter YOUR chosen private password
4) Choose pay by credit card (You are not charged any FEE)
5) Enter pay to "firstname.lastname@example.org"
6) Enter amount: $500, $100, $50 etc.
7) An electronic receipt is automatically sent to your e-mail, to indicate approved transaction.
8) 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.