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APRA-Carolinas Membership
Form/Invoice
APRA-Carolinas Dues for the Year 2012 (1/1/2012 – 12/31/2012) $35
Please write your name below and fax it to Chris Nuckols, Membership Chair at 336-716-7168 or e-mail at cnuckols@wfubmc.edu ...
If you are a renewing member, and there are any changes
to your directory listing as it currently appears
in the membership directory
, please indicate them below. Your Name: ___________________________________________________________________________
Your Title: _____________________________________________________________________________ Name of Your Institution: __________________________________________________________________ Address: ______________________________________________________________________________ City/State/Zip Code: _____________________________________________________________________ Telephone Number: _______________________________________________________________________ Fax Number: ___________________________________________________________________________ Email Address: _________________________________________________________________________ Please mail your check to: |