New Jersey Society of Interventional Pain Physicians



23026-994NEW JERSEY SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS(An Affiliate of the American Society of Interventional Pain Physicians)26 Eastmans Road -- Parsippany, NJ 07054973-597-0938 Fax: 973-597-02412020 Annual Membership Application/Dues Renewal Form Name _____________________________________________Preferred Mailing Address___________________________________City _______________________State__________ Zip Code____________Phone ______________________Fax____________________________Email Address______________________@____________________________NJ Medical License Number(or other professionally regulated license#)______________________I hereby Join/ Renew:_____$150.00 - ACTIVE MEMBERSHIP (Must be a Physician Specializing in Pain Management, Spinal Injections or Neural Blockade)_____$150.00 - ASSOCIATE MEMBERSHIP (Non-Pain Management Physicians, Scientists, Nurses, Physicians Assistants, Nurse Practioners, Administrator, Pharmacists, Physical Therapists, Psychologists who are associated with an active practice of Pain Management)_____ NO FEE - FELLOWS, RESIDENTS & MEDICAL STUDENTS Dues can be paid online at: or by check made payable to: NJSIPPand mail to: 26 Eastmans Road Parsippany, NJ 07054 ATTN: Linda Bartolo ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download