Application to IHE Europe

A. Organisation Information

Legal entity name*

Address*

City*

Postal code*

Country*

Website

B. Membership category and fee

At the date of signature, our organisation falls into the following category - please tick your choice

National Deployment Initiative - € 4000 (incl. IHE International fee)

Vendor Associations - €4100

Large Vendors (>2500 FTE) - €4100

Mid-Sized Vendor (250-2500 FTE) - € 2100

Small Vendors (< 250 FTE) - €1000

User Organisation - € 600

Competence Center - € 600

Government Agency - € 2100

Benefactor - € 0

* Note that 21% VAT will be added to the fees where applicable.

C. Representative contact information

We nominate the following person as the general representative of our organisation towards IHE-Europe:

Name*

Title*

Address*

Postal code*

City*

Country*

E-mail address*

Re-enter e-mail address*

Phone number*

Mobile Number

Fax

For National Initiatives

We nominate the following persons as the general representatives of our organisation towards IHE-Europe

User Co-Chair

Name

Title

E-mail address

Phone number

Mobile Number

Fax

Vendor Co-Chair

Name

Title

E-mail address

Phone number

Mobile Number

Fax

D. IHE-Europe Committees

We are interested in nominating a representative for the following Committees:

EU Affairs Committee

MarCom Committee

IHE-Services Committee

*Note: To join IHE-Services, you have to file a separate application. For further information, please contact secretariat@ihe-services.net

I agree to the Policies of IHE-Europe.*

I agree to the Intellectual Property Agreement*

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