HSLANJ Membership Form
Membership Year - April 1, 2018 - March 31, 2019
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Title *
Your answer
Institution
Your answer
Library Name
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
ZIP *
Your answer
Telephone - including extension, if applicable *
Example: (123) 456-7890 ext. 1234
Your answer
Fax
Example: (123) 654-0987
Your answer
Email *
Your answer
Support Staff
List other members of your library staff you would like to include in the directory. Please include their job title, phone number, and email address. If they want to be individual members, they MUST full out an additional form
Your answer
Membership Type *
Please click here for important information on Membership Types: http://hslanj.org/about/join-contact-hslanj/
Required
I am a: *
Required
DOCLINE Participant *
Required
LIBID
Your answer
AHIP: Academy of Health Information Professionals Membership Status *
Required
CHIS: Consumer Health Information Specialization Status *
Email Authorization: by checking the appropriate box below, I understand and acknowledge the following: *
Required
Photography: by checking the appropriate box below, I understand and acknowledge the following: *
Required
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