Membership Application | PRE-Hospital Stroke Treatment Organization

Industry Membership App

Thank you for applying for Industry Membership with PRESTO!

Industry Membership Definition: a partner within the in pre-hospital stroke management field. The company will pay dues on behalf of two staff members.

Upon completing this application and paying dues, two of your company's representatives will be considered members of PRESTO. Your dues payment of $2,000 plus a $60 credit card processing fee will be charged to your card. If you would like to avoid the processing fee, please complete the PDF membership application found under the Industry Membership dropdown, located under the Membership tab.
*Additional representatives may be added for $200 each.

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

Membership Dues

Industry Code

If someone from the PRESTO Executive Office gave you a code to sign up for an organization, enter it now and hit the Apply button.
Otherwise, skip this section.

Your Dues Rate Type is: Industry $2,000.00

Add-On (PRESTO Office Use Only)

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 *

Additional Information

Please list the individuals who should be included under this organizational membership (excluding yourself):

Individual 1: Name (include credentials)

Email:

Individual 2: Name (include credentials)

Individual 3: Name (include credentials)

Individual 4: Name (include credentials)

Individual 5: Name (include credentials)

Individual 6: Name (include credentials)

Individual 7: Name (include credentials)

Individual 8: Name (include credentials)

Individual 9: Name (include credentials)

Individual 10: Name (include credentials)

Additional Options

Industry supporters paying by credit card are assessed a $60 processing fee.

Credit Card Processing Fee - $60.00

Payment Details

Check Payment Code:

PRESTO is partnering with Genentech, 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.

Industry Membership App

Thank you for applying for Industry Membership with PRESTO!

Membership Dues

Contact Information Contact Information

Username/Password Username/Password

Additional Information Additional Information

Additional Options Additional Options

Payment Details Payment Details

Contact Information

Additional Information

Additional Options

Payment Details