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
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