NJ
Association of Sleep
Technologists NJAST
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NJ Bill Affects Ambulatory Care Centers
November 15, 2008
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Please Print and Complete the Information Below and Mail this form with your check (Please make checks payable to New Jersey Sleep Society ) and mail to: New Jersey Sleep Society, Inc. 390 Route 10 Suite 101 South Building Randolph, NJ 07869 Phone: (973) 361-1766 Fax: (973) 361-4054
Registration Form –NJSS Annual Educational Symposium Saturday November 3, 2007
Fees: □ $125.00 - MD, DDS, DMD, PhD □ $60.00 –PSG Technologist, Respiratory Therapist, Medical Resident/Fellow, & Other Attendees □ $50.00 –NJ Association of Sleep Technologists (NJAST) Member
Name: Degree/Title:
Address: City: State: Zip:
Phone: Fax: E-mail:
Please make your check payable and mail to: New Jersey Sleep Society 390 Route 10 Suite 101 South Building Randolph NJ 07869
To pay by credit card mail or fax application: □ VISA □ MasterCard
Name on card :
Billing address (if different from above): Card Number : __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp. Date mo./yr. ___/___
Amount charged $
Signature:
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