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Membership Application

To join the Friends of the Institute, please complete this form and mail it with your payment to the Texas Institute for Health Policy Research.

Ms.
Miss
Mrs.
Mr.
Mr. & Mrs.
Rev.
Dr.
Drs.
Other __________

Name:

Company:

Title:

Mailing Address:

City, State, Zip:

Phone Fax:

Please begin my Friends of the Institute membership at the following level:

Level Amount

    Rising Star Sponsor (Student) - $25-$99
    Lone Star Sponsor (I) - $100-$499
    Bronze Star Sponsor (II) - $500-$1,499
    Silver Star Sponsor (III) - $1,500-$4,999
    Gold Star Sponsor (IV) - $5,000-$7,499
    Platinum Star Sponsor (V) - $7500-$12,499
    Founder's Star Sponsor (VI) - $12,500 and above


Method of Payment:

Check $
Cash $

Membership Application
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