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Please complete the registration form below.

Organization:

International Psycho-Oncology Society

Event:

Donations to IPOS

Date/Time: Sun, 01-Jan-2017 - Thu, 31-Dec-2020

First Name:    (*)
Last Name:    (*)
Address:     (*)
Unit #: 
City:     (*)
Postal/Zip Code:     (*)
Prov./State:   (for Canada and US applicants only)
Country:     (*)
Primary Phone:     (*)
Email:     (*)
  I have read and agree with the Terms of Use   (*)
 
 
Company/Institution:   (*)
 
Please use the following name(s) in all acknowledgements of the donation:
Acknowledged Name(s):   (*)
Your donation gift is:
 
 
 
Please indicate what you would like your donation to be attributed to:
Attribute to:
 
IPOS will send a letter of sympathy to the bereaved if your gift is in memory of the named person(s). If your gift is in honor of the person(s) named above, IPOS will send the honoree(s) notification of your gift.
Do you wish to have IPOS to send a notification?: Yes    No    N/A    (*)
Please provide the appropriate contact information below. (Name, Street, City, State/Prov., Zip +4 or Postal Code, Country)
Honoree(s) Contact Name(s):
Honoree Full Address:
 
Please provide any comments you would like included in IPOS’ letter to the honoree/bereaved:
Comments to include:
 
Please note the following recognition levels for donations (in US dollars):

Legacy Circle: $5,000 and up
Champion: $1,000 – $4,999
Partner: $500 – $999
Patron: $100 – $499
Friend: up to $99
Please indicate the dollar value you wish to contribute:
Donation Amount:  Format 0.00   (*)
    (*)
 (*) required field
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