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ORGANIZATIONAL AFFILIATE program application Please complete the form below and mail or fax to: HISS Middle East, Phone: +44 755 733 7066 Fax: +32 2 793 7631 Email: Roberts hiss.org Healthcare Organization
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2012 2013 HIMSS HCO 1st USD8000 USD12000 MasterCard JPMorgan USD4000 USD2000 Cardholders srobertshimss favouring ABA applicable AFFILIATE ORGANIZATIONAL Healthcare payable org Expiration invoice Revised transfers faxed Provider enclosed

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