Application for Membership
Name:*
Mr.
Mrs.
Ms.
Dr.
Firm:
Business Address:
Business Phone:
(
)
-
x
Home Address:*
Home Phone:
(
)
-
Email:*
Educational Background:*
Professional Background:*
Sponsor:
(any current member)
*Required
If you have questions about this application, please contact
Ms. Gloria Nixon
at:
nyumm@hotmail.com
718-981-1746