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MLA NY-NJ Chapter Online Membership Form:
MembershipType:	New Member Renewing Member
Name:
Job Title:
Business Address(this address will be listed in the Chapter Directory):
Institution:
Library:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
FAX:
Email:
Add me to (or do not remove me from) the chapter listserv. Do not add me to (or remove me from) the listserv. I waive my right to participate in all chapter business conducted via the listserv.
Mailing Address(only if different from above):
Address 1:
City:
State:
Zip:
Are you currently a member of the Medical Library Association (national)? Yes No
AHIP?	Yes No
	Level: Distinguished Senior Member Provisional Valid Through: 2011 2012 2013 2014 2015
Are you interested in being contacted about joining a Chapter committee or filling a Chapter position? Yes No Specify: