NMPRA Membership Form

Hand with PenThank you very much for your interest in joining NMPRA.

Currently membership is free through June, 30, 2002.

Membership entitles you to our quarterly newsletter, participation in nmpra-l, and the ability to apply for our two $1,000 scholarships.

To become a member, fill out the form below. 

1. General Information


First name                
Last name                 
Daytime phone number      
Evening phone number      
Email address             

2. Program Information


Program Name      
PGY               

3. Standard Mail
   
   
Address line 1  
Address line 2  
City            
State/Province  
ZIP/Postal Code 


4. Additional Information 
       
Would you like to be your program's Program Representative?
Comments/questions:


For questions or additional information regarding this membership application, please contact the NMPRA Coordinator, Gaines, Renee at rgaine@lsuhsc.edu.

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