Membership Registration Form This form allows you to become a voting or non-voting member of GS1 Healthcare, the global healthcare user group. GS1 Healthcare welcomes the following stakeholders as voting members: pharmaceutical or medical device manufacturers, wholesalers, distributors, group purchasing organisations, hospitals, pharmacies, solution and logistics providers. Associations, regulatory bodies, educational institutes and other standards bodies can be non-voting members with no voting privileges. For full details, please refer to the GS1 Healthcare Governance Charter at http://www.gs1.org/healthcare/about/charter_roadmap. Company Details Company : Main area of activity : Company address : City & State : Postal/ZIP code : Country : VAT number for EU members :
Your Contact Details Mr. Ms. Mrs. Dr. First name : Last name : Job title : Mailing address (if different than above) : Telephone number : Email : Secondary Contact Details (if applicable) Mr. Ms. Mrs. Dr. First name : Last name : Telephone number : Email : 2
Membership I am a local member of a GS1 Member Organisation (prerequisite) Please specify the country of the MO: I am a manufacturer, distributor, wholesaler, group purchasing organisation, logistics or solution provider or government agency (non-regulatory) and want to become a voting member of GS1 Healthcare Annual revenues (in ) < 10 million or Hospital* 2,800 10 million 100 million 8,500 100 million 500 million 11,000 500 million 1 billion 17,000 1 billion 10 billion 28,000 10 billion 20 billion 39,000 >20 billion 50,000 GS1 Healthcare 2017 membership fee (in ) I am a hospital and want to become a voting member of GS1 Healthcare (exempt from membership fee) I am an association, regulatory body, educational institute, standards body and want to become a non-voting member of GS1 Healthcare (exempt from membership fee) Special invoicing requirements Printed version of the invoice PO number if requested by your company If yes, this number should be shared with us as soon as possible Invoice in USD Specific invoicing submission system Comments 3
Voting Membership Criteria All parties operating in the healthcare supply chain may become voting members of GS1 Healthcare, including, but not limited to, suppliers, wholesalers / distributors, hospitals, pharmacies and specified government agencies. GS1 Healthcare Voting Members must be a member of a GS1 Member Organisation (MO) and must have communicated their interest in the use of global standards to improve patient safety. More than one individual can represent a voting member organisation; however, each voting member organisation is only allowed one (1) vote in any ballot or election activity. Government agencies are those organisations solely funded by government, representing national / regional / state / provincial interests who actively procure product or clearly represent government organisations that do procure. Government agencies eligible to be considered voting members of GS1 Healthcare must not be responsible for setting regulations relating to supply / identification / traceability / recall of product, however these organisations may set requirements (i.e., terms of trade) for provision / use of GS1 standards as part of procurement activity. Voting members of GS1 Healthcare contribute to GS1 Healthcare activities and basic operational costs with an annual fee to GS1 Healthcare. Members are only eligible to vote once they have paid their annual membership dues. Membership renewal fees are due on the 31 March. Either party may terminate this agreement without cause by serving a written notice to the other party. Any such notice shall be served by registered mail by 30 September and shall terminate this agreement with automatic effect on 1 January of the following calendar year (effective date of termination). During the period from the date on which notice has been served, and the effective date of termination, all terms and conditions of this agreement shall remain valid and in full force and effect. Voting members have voting rights in the development of global standards and password-protected access to all documents. They can have access to the Public Policy database developed by GS1 Healthcare. With the exception of government agencies, voting members can participate in the Public Policy work group. Voting members can also be candidates for the Leadership Team and the chair positions of GS1 Healthcare. Non-voting Membership Criteria Organisations with a keen interest in standards development and patient safety may support GS1 Healthcare by participating in the efforts of the GS1 Healthcare work teams. Non-voting members are eligible to become members of GS1 Healthcare work teams, attend GS1 Healthcare events, and will have access to standards development work team documentation, but will not have voting privileges. Non-voting membership is limited to trade associations, regulatory bodies and other governmental healthcare authorities, educational institutes and other standards bodies. All other organisations and firms are eligible for voting membership. Payment & Authorisation Payment method: bank transfer 4
I agree to the use of my personal data provided with this application to administer the GS1 Healthcare Membership and working groups. For more information please see our Privacy Policy at http://www.gs1.org/privacy. Authorised signature: Date: Scan or mail completed form to GS1 AISBL Sophie Molle, Manager, GS1 Healthcare Avenue Louise 326, box 10, 1050 Brussels, Belgium Email: sophie.molle@gs1.org 5