NSFDA New Member/Renewal Application

Firms

Firm Name:

Firm's NYS Reg. #:

Designee LFD Owner/MGR/Employee:

NYSFDA Member?:

 Y

 N

NYS Pocket Card #:

Fees:

Regular Firm Plus Designee ($350.00)

Address

Address:

 

City:

Country:

State/Province:

Zip/Postal code:

Telephone:

Fax:

 

E-mail addresses for every individual member are essential. All Meeting notices and informational messages are sent by e-mail as well as the Newsletter. Only Firms will receive the newsletter by mail.

E-mail:

Web Address:

 

Please list four NSFDA member firm designees who have agreed to sponsor your membership

New Firms Applying for Membership Only:

Note: Email addresses for every individual member are essential. All meeting notices and informational messages are sent by e-mail as well as the Newsletter. Only firms will receive the newsletter by mail. 

Do you wish to add an affiliate?

Add an Affiliate

$25.00

no

Affiliate 1

Name of First Affiliate:

Email for First Affiliate:

Cellphone:

NYS Pocket Card #:

Add another affiliate?

Add a second Affiliate

$25.00

No

Affiliate 2

Name of Second Affiliate:

Email of Second Affiliate:

Cellphone:

NYS Pocket Card #:

Add a third affiliate?

Add a third Affiliate

$25.00

No

Affiliate 3

Name of Third Affiliate:

Email of Third Affiliate:

Cellphone:

NYS Pocket Card #:

Add a fourth affiliate?

Add a fourth Affiliate

$25.00

No

Affiliate 4

Name of Fourth Affiliate:

Email of Fourth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a fifth affiliate?

Add a fifth Affiliate

$25.00

No

Affiliate 5

Name of Fifth Affiliate:

Email of Fifth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a sixth affiliate?

Add a sixth Affiliate

$25.00

No

Affiliate 6

Name of Sixth Affiliate:

Email of Sixth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a seventh affiliate?

Add a seventh Affiliate

$25.00

No

Affiliate 7

Name of Seventh Affiliate:

Email of Seventh Affiliate:

Cellphone:

NYS Pocket Card #:

Add an eighth affiliate?

Add an eighth Affiliate

$25.00

No

Affiliate 8

Name of Eighth Affiliate:

Email of Eighth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a ninth affiliate?

Add a ninth Affiliate

$25.00

No

Affiliate 9

Name of Ninth Affiliate:

Email of Ninth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a tenth affiliate?

Add a tenth Affiliate

$25.00

No

Affiliate 10

Name of Tenth Affiliate:

Email of Tenth Affiliate:

Cellphone:

NYS Pocket Card #:

Add an eleventh affiliate?

Add an eleventh Affiliate

$25.00

No

Affiliate 11

Name of Eleventh Affiliate:

Email of Eleventh Affiliate:

Cellphone:

NYS Pocket Card #:

Add a twelfth affiliate?

Add a twelfth Affiliate

$25.00

No

Affiliate 12

Name of Twelfth Affiliate:

Email of Twelfth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a thirteenth affiliate?

Add a thirteenth Affiliate

$25.00

No

Affiliate 13

Name of Thirteenth Affiliate:

Email of Thirteenth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a fourteenth affiliate?

Add a fourteenth Affiliate

$25.00

No

Affiliate 14

Name of Fourteenth Affiliate:

Email of Fourteenth Affiliate:

Cellphone:

NYS Pocket Card #:

Add a fifteenth affiliate?

Add a fifteenth Affiliate

$25.00

No

Affiliate 15

Name of Fifteenth Affiliate:

Email of Fifteenth Affiliate:

NYS Pocket Card #:

Cellphone:

Student

Name:

E-mail:

Cellphone Number:

School:

Estimated Graduation Date:

Pocket Card # (If Resident):

The fee for a Colleague is $75.

Colleagues

Name:

E-mail:

Check One:

Colleague ($75.00) Emeritus ($25.00)

Name:

NYS Pocket Card #:

Address

Address:

 

City:

Country:

State/Province:

Zip/Postal code:

Telephone:

Fax:

E-mail:

The fee for an Emeritus is $25.

Emeritus

Name:

E-mail:

Check One:

Colleague ($75.00) Emeritus ($25.00)

Name:

NYS Pocket Card #:

Address

Address:

 

City:

Country:

State/Province:

Zip/Postal code:

Telephone:

Fax:

E-mail: