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MLA NY-NJ Chapter Online Membership Form:
Membership Type:	New Member Renewing Member
Name:
Job Title:
Business Address (this address will be listed in the Chapter Directory):
Institution:
Library:
Address 1:
Address 2:
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Zip:
Phone:
FAX:
Email:
Add me to (or keep me on) the chapter listserv. Do not add me to (or remove me from) the listserv. I waive my right to participate in all chapter business conducted via the listserv.
Mailing Address (only if different from above):
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Are you currently a member of the Medical Library Association (national)? Yes No
AHIP?	Yes  No
Level: DistinguishedSeniorMemberProvisional	Valid Through: 20182019202020212022202320242025
Are you interested in being contacted about joining a Chapter committee or filling a Chapter position? Yes  No If yes, Specify: