American Association of Physicists in Medicine
New England Chapter
2006 Membership Application and Renewal Form
No changes from last year? Just fill in your name and Circle
No Changes
Name:
Institution:
Mailing Address:
E-Mail Address:
Phone:
FAX:
Specialty:
Other:
Health
Physics
Nuclear
Medicine
Radiation
Oncology
Radiology
Membership Category
(check one)
Member: Full, Junior or Emeritus member of the national AAPM
Associate Member: Person interested in the purpose of the chapter (not a full AAPM member)
Student Member: Student or trainee in an accredited college, university or training program
Dues:
Member or Associate Member: $25
Student Member: Complimentary
No Charge if you were a speaker at a NEAAPM meeting last year
Privacy
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wish your name to be included in Corporate Affiliate mailing lists
Or fill in an alternate mailing address
Please make checks payable to:
New England Chapter, AAPM (or simply "AAPM")
Send completed form and check to:
Erli Chen, MS, DABR
Office: (603) 354-6500
Radiation Oncology
Fax: (603) 354-6501
Cheshire Medical Center
echen@cheshire-med.com
580 Court Street
Keene, NH 03431