Practice/Adjunct Membership Registration Form

Please complete this application by filling in the fields below.
Consider enrolling additional staff members as some of our
meeting topics appeal directly to your support staff.

 

Date: (month/day/year, 1/20/2012)
 
I am a:
Membership Type:
 
Name:
Title:
 
Practice/Organization Name:

(Please enter your company’s name exactly as it should be listed on marketing materials)
Practice/Organization Address:
Practice/Organization Address 2:
Practice/Organization City/State/Zip: / /
 
Phone Number:
Fax Number:
Email:
 
Information to be sent to:
 
Home Address:
Home Address 2:
City/State/Zip: / /
 
As a HOMNY Member I authorize the use of fax and email to communicate chapter activities
   
As a HOMNY Member I authorize the use of photographs taken at membership meetings to be used for marketing/advertising purposes
   
 
Username for members only area on www.homny.org (case sensitive)
 
Password for members only are on www.homny.org (case sensitive)
   

Note: Access to your account will be available within 48 hours of receiving your membership dues payment.
Do you have any questions or comments regarding HOMNY membership?
   
   
   
   
Please choose membership option:

   

You will be asked to enter your credit card information using PayPal’s
secure bill pay form
   

Please mail check made payable to HOMNY to:
Hematology-Oncology Managers of New York
PO Box 1243
Lake Grove, NY 11755
   

Membership is valid for the calendar year in which you sign up and expires on December 31 of the same year.

Note: This form is available as a PDF, which you can print, fill out, and fax/mail to HOMNY
   
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