New York Society for
Healthcare Consumer Advocacy
MEMBERSHIP APPLICATION
7/05 to 6/06
Name: ____________________________________
Title: _____________________________________
Institution: ________________________________
Work Information
Work Address: _____________________________________
Room Number: _____________________________________
Town, State/Zip Code: ________________________________
E-mail Address: _____________________________________
Telephone Number: __________________________________
Fax Number: _______________________________________
Personal Information***
Home Address: _____________________________________
Town, State/Zip Code: ________________________________
E-mail Address: _____________________________________
Telephone Number: __________________________________
Fax Number: ________________________________________
***Personal information will only be placed on the Internet if there is no employment information listed. Personal information may also by used by our Board Members to locate you should change employment.
Membership Category:
_____$45 Regular
_____$35 Student _____Honorary (no charge for retirees)
Please return this completed form with a check made payable to NYSHCA at:
NYSHCA
81 Erie Street
Campbell Hall, NY 10916
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