Please print this page for your records and include a copy when sending your check to:

Dear First_Name,

You have successfully joined or renewed your membership with NY Metro ASHI^® .

The following is the information you entered:

First_Name  MI  Last_Name

Title, Company
Street
City, State  Zip

Work Phone: Work_Phone

Cell Phone: Cell_Phone

FAX: FAX

E-mail: Email

Website: Website

Membership Type: ASHI_STAT

Member/Candidate #: ASHI_NUMBER

State License Number

NY-NY_LIC_NUM            CT-CT_LIC_NUM

NJ-NJ_LIC_NUM             MA-MA_LIC_NUM

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Revised: March 11, 2012 .

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Copyright © 2004 NY Metro Chapter
Last modified: March 11, 2012