vvNew England Society of Clinical Engineeringvv

2010 Membership Form

Type of Membership:

rCorporate ($100 for up to 10 members)   rIndividual ($15)   rStudent ($5)

Name: __________________________________________________________

Title: ___________________________________________________________

Education: ______________________________________________________

Certification: rCBET   rCCE   rOther _______________________________

Area of Expertise: _________________________________________________

Employer: _______________________________________________________

Department: _____________________________________________________

Address: ________________________________________________________

Tel. Number: _______________________

Fax Number: _______________________

Work E-mail Address: _______________________________________ (required)

Home Address: __________________________________________________

Home Tel. Number: _________________________

Personal E-mail Address: ____________________________________ (required)

Newsletters and meeting notices are distributed by e-mail.  Please include yours.

Send completed application with check made out to "NESCE" for one year’s dues to:

New England Society of Clinical Engineering

35 Grandview Drive

Trumbull, CT 06611