Northern Mountain
Branch
American Association For Laboratory
Animal Science
2010 MEMBERSHIP APPLICATION
New Member
Type of Membership (check one)
____Individual $15.00
____Vendor – Bronze $75.00
____Vendor – Silver $250.00
____Vendor – Gold $350.00
Renewal Member
(Includes membership and newsletter)
(Includes membership and 1 business card advertising in newsletter )
(Includes membership, 1 business card advertising and up to full page
advertising in newsletter)
(Includes membership, 1 business card advertising, up to full page
advertising in newsletter, and sponsorship at one meeting)
NMB-EN: 03-0365292
Name:
______________________________________________
Position/Title:
______________________________________________
Employer:
______________________________________________
Business Address: ______________________________________________
Business Phone:
______________________________________________
E-mail Address:
______________________________________________
□ ALAT □ LAT □ LATG □ CMAR Registered? □
Credentials: □ AAS □ AS □ BS □ BA □ MS □ DVM □ ACLAM Cert
Are you a National Member? □ Yes Membership # ___________________
□No
Would you like to join the AALAS Learning Library (ALL)? □ Yes (branch covers fees)
□ No
Certification Level:
Signature of Applicant:
Please mail to:
__________________________________________
Rose Bartiss
Make checks payable to:
Trudeau Institute
Northern Mountain AALAS Branch
154 Algonquin Ave.
Saranac Lake, NY 12983
Office use only:
Date Rec’d:__________ Amt Rec’d:___________ Member # Assigned:_____________
Business card rec’d for vendors only: Y or N