Health Humanities Consortium Membership

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Title

Prof.

Dr.

Mx

First Name*

Middle Initial

Last Name*

Title*

Institution/Company*

Department/Division

Office Address*

City*

State/Province*

Zip Code*

Country*

Business Phone*

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Are you:*

Faculty

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Other

Membership Categories*

Institutional --$1,000

Individual--$100

Student--$25

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