Florida Hospital Association PC

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Thank you for your support. The FHAPC is committed to shaping the discussions and policy issues that impact our patients, employees, and communities. By investing in FHAPC, you are ensuring that the voice of Florida hospitals is heard loud and clear.

For additional information, please contact David Mica, Jr., FHA Executive Vice President of Public Affairs, at (850) 222-9800.

Recognition Level	Contribution Amount
President's Club:	$1,500
Chairman’s Club	$750
Capitol Club:	$500
VIP Club:	$250

Contribution Amount

Choose A Frequency

Recurring Frequency:

Total: $0.00

Prefix:

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Additional Information

Hospital Name: *

Employer:

(if different from Hospital name)

Employer Phone: *

Occupation/Title: *

Hospital Management

Hospital Trustee

Vendor

Auxilian

Medical Staff

Salaried

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State/Federal law governs all contributions. Reporting of this information is required.

Your Payment Information

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