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Regional OMS Association Contribution Registration

Regional OMS Association Contribution to the IAOMS Foundation
     Association Information all * marked fields are mandatory
Name of Association: *  (250 characters)
President's Name: *  (100 characters)
Term: *
IAOMS Councilor’s Name: *  (100 characters)
Term: *
Secretary's Name: *  (100 characters)
Term: *
Treasurer's Name: *  (100 characters)
Term: *
Association Email Address: *  
Association Website :  (i.e,www.iaoms.org)
     Contact Information
     Mailing Address
Street: *
Street:
City: *
State:
Postal code:
Country: *
     Telephone Numbers
Country/Area/Number
Telephone #: *   
Fax #:   
  
     How Do You Wish To Be Contacted?
     Contribution to IAOMS Foundation
Contribution Amount: *         $
     Payment Details
Total Amount Due $
 

Mode of Payment*

 
Fed. Reference # *
Date of Transaction
 *
Pay via Bank Transfer with SWIFT
(Please find our bank account information on next page)
    Next Page
 
            Name of Bank * (American Bank Draft only )
            Branch *
           Date  
           Draft No. *