Membership Application Form 申请表
DIVERSE IPA INC.132-29 Blossom Ave 1ST Floor，Flushing, NY 11355
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Organization Name 公司名称 *
Organization Name（Chinese）公司中文名称
NPI *
Owner Name 持有者名字 *
Organization Address 地址 *
Phone Number 电话号码 *
Email 电子邮件 *
Application Fee 申请费 $60
The check mst be issued by the organization name same on the application form.开支票的公司与申报表上的公司名称须一致
I agree to become Diverse IPA member & undertake that I will sign all such other documents and so all such ascts.I Hereby Agree to Abide by the present and future rules of Diverse IPA Inc.我同意成为 Diverse IPA 会员，并承诺将签署所有其他文件及所有此类行为。我在此同意遵守 Diverse IPA Inc. 的现在和将来的规则。 *
Required
Applicant Name申请人姓名 *
Title 职位 *
Date 申请日期 *
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