Membership Application | Histiocyte Society

Membership Dues

Application Fee: $175.00

Your Dues Rate Type is: Active Regular Member $175.00

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Last Name *

Suffix

Title

Informal Name

Institution

Address Line 1 *

Address Line 2

Address Line 3

City *

State

Zip Code *

Country

Personal LinkedIn URL or Handle

Personal X (Twitter) URL or Handle

Personal Facebook URL or Handle

Personal Instagram URL or Handle

Profile Photo

Phone Number *

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Username/Password Username/Password

Please enter the Username/Password you would like to use to login to this website.

Your Username must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Username *

Password *

Confirm Password *

Payment Details

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing Histiocyte Society to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting Histiocyte Society, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Total Amount Due

$

New Member Application: Regular

Membership Dues

Contact Information

Username/Password Username/Password

Additional Information

Payment Details

New Member Application: Regular

Membership Dues

Contact Information Contact Information

Username/Password Username/Password

Additional Information Additional Information

Payment Details Payment Details

Contact Information

Additional Information

Payment Details