The ACPE Research Network

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ACPE RESEARCH NETWORK MEMBERSHIP INVOICE
April 2017 to April 2018
 
[You may complete this form on your computer, and then PRINT IT OUT and mail it with your dues to the address noted at the bottom. You may also print out the blank form and complete it by hand.]

Check one:
$20 Individual One-Year Membership
$50 Institutional One-Year Membership
$250 ACPE Region One-Year Membership

Name:

Phone:

E-mail:

Mailing address line 1:

Mailing address line 2:

Mailing address line 3:

Mailing address line 4: (optional)

Mailing address line 5: (optional)

Institution: (if not in address)

Make your check payable to ACPE Research Network,
and send with a copy of this invoice to the Network Convener:
Chaplain John Ehman
Pastoral Care Dept., W-108
Presbyterian Medical Center
51 N. 39 St.
Philadelphia, PA 19104

NOTE: Federal Tax Identification Number 58-192-1094

Please keep a copy of this completed invoice for your records.
Thank you for supporting the ACPE Research Network.