Personal Information:
Name:
Company name:
Work Address:
City, State, Zip (please include +4):
Home Address:
City, State, Zip:
Please Indicate your preferred mailing address: Home Work
Home Phone: Work Phone:
Fax: E-mail:
Please join us today as a Member!
To become a member, return this form, along with a check for $80.00 for your annual dues ($40.00 for student members) to:
Ganimet Brija, Treasurer
11 Gary Place
Selden, NY 11784
Professional Information:
Type of Employer:
Government Educational
Professional Services Health Facility/Med. Ctr.
Finance/Insurance Retail Service
Retail Trade Construction/Real Estate
Assoc./Non-Profit Other
Communications Self Employed
Manufacturing
Workplace Profile; Number of Employees:
1-10 11-50 51-100 101-500 over 500
If a Member assisted you in learning more about our organization, please list her/his
name here so we may thank her/him:
Name/Member ID (if known)
