NYSALM MEMBERSHIP FORM 2008

Personal Information

Name: ________________________ Title: CNM / CM / SNM / SM

Address: _________________________________________________

City: _____________________ State: ______ Zip Code: ____________

Phone: _____________________ Email: _________________________

Practice Information (please include a business card)

Name: ____________________________________________________

Address: __________________________________________________

City: _____________________ State: ______ Zip Code: _____________

Phone: _____________________ Fax: ___________________________

Website: __________________ Email: ____________________________

___Check if you DO NOT want your practice information listed in the NYSALM Directory

___Check if you would like the newsletter sent via postal mail instead of email

NYSALM District (select one) :

Employed by (Check all that apply):

Type of Practice

Site of Deliveries (Check all that apply):

Number of Births You Attend Per Year:

Total Number of Births Per Practice Per Year: ___________

Does Your Pratice Precept Students: Yes / No

If Yes, What Type of Student? (Check all that apply):

Educational Degrees (Check all that apply):

Malpractice Insurer:

Clients Served (enter percent):

Membership Categories:

Donation for legislative effort (optional): $_______

Donation for organization needs (optional): $_____

Contributions or gifts to NYSALM are not tax-deductible
as charitable contributions; however some portion of membership
dues may be tax-deductible as ordinary and necessary business expenses

___ Check here if you would rather recieve postal mail than email

Please send your check, payable to NYSALM, to the following address:

NYSALM
138 Mountain Road
Pleasant Valley, NY 12569