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Individual Consortium Membership Application

Individual consortium membership entitles the member to attend all Upstate AHEC programs at no charge for registration. Meals, roster fees and books, if required for a specific program, are not included in consortium membership.

Consortium membership is not transferable and membership fees are nonrefundable.

Membership fee for July 1, 2008 - June 30, 2009 is $150.00.

Name
Employer
Home Address
City
State
Zip
Telephone: Business
Telephone: Home
Licensure/Credentials
E-mail

I am interested in receiving information about programs for the following disciplines:

CHES
Occupational Therapist/OTA
Counselor/Therapist
Pharmacist
Dental Hygienist/Assistant
Physical Therapist/PTA
Dentist
Registered Nurse/LPN
Dietitian
Respiratory Therapist
EMT/Paramedic
Social Worker
Nurse Practitioner
Radiological Technologist
Other 

When you click the submit button, you will be re-directed to a payment page.

You may also print this form out and send it to us with your check to:
Upstate AHEC
14 Progress Road
Greenville, SC 29607

Or you may fax it to us at (864) 349-1179

Registration Line (864) 349-1177

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