Asociación Latinoamericana de Cuidados Paliativos

Membership and Renewal

Please, complete this form.

Type (select one)
New individual membership	Renewal individual membership number
New institutional membership	Renewal institutional membership number

(* required fields)

Name and last name / Institutional name	*
Address	*
City	*
Zip Code
State	*
Country	*
Telephone
Fax
E-Mail	*
Profession	*
Specialty
Name of place of work
Position

Professions	For one year	For two years	Lifetime (**)
Volunteers	USD 15	USD 30	USD 350
Students	USD 15	USD 30	USD 350
Others Health Professionals	USD 25	USD 50	USD 350
Physician	USD 50	USD 100	USD 350
Institution	USD 100	USD 200
(**) The Lifetime members carries out an unique payment of US $350 and they maintain its membership of for life

Credit Card

Credit card

VISA Argencard Master Card

Last Name on Credit Card *

First Name on Credit Card *

Credit Card Number *

Expiration date (mm/yy) *

Transfer with Western Union

Addressee:
Ana Carolina Monti - Gerente Admnistrativa ALCP
Belgrano 141; (2900) San Nicolás; Bs. As. - Argentina

Transference Number

By cash