Membership Application | PRE-Hospital Stroke Treatment Organization

Individual Membership App

Thank you for applying for Individual Membership with PRESTO!

Individual Membership Definition: Scientists, physicians, health care providers, or other professionals who are significantly involved in the clinical or scientific aspects of pre-hospital stroke care, shall be eligible.

Upon completing this application and paying dues, you will be considered a member of PRESTO. Your dues payment of $200 will be charged to your card.

Email us at connect@prestomsu.org if you have any questions.

Membership Dues

Your Dues Rate Type is: Individual $200.00

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Suffix

Title *

Informal Name

Company *

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Country *

Website

Personal LinkedIn URL

Personal Twitter URL

Personal Instagram URL

Profile Photo

Phone Number *

Fax Number

CC Email

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

Check Payment Code:

PRESTO is partnering with Genentech, Siemens, other stakeholders, and CRD Associates, a Washington DC consulting group, to explore and then pursue mechanisms with CMS to achieve appropriate reimbursement for MSU activities. We invite our members to add an additional donation to their annual dues to help defray these costs. As this is not a proprietary PRESTO activity, we suggest an additional $1000 per organization or industry member, and $100 per individual member, but any contribution is appreciated.

With your continued support, we will continue to advance excellence in research in the field of pre-hospital stroke treatment.

Optional CMS Donation

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 PRE-Hospital Stroke Treatment Organization 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 PRE-Hospital Stroke Treatment Organization, 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

PRESTO is a 501(c)3 non-profit status, which enables your dues to be tax deductible. Please work with your tax advisor to determine how to claim this as a deduction.