THE NEW ENGLAND HAND SOCIETY

New England Hand Society
2008 Membership Dues Invoice

(check one)
2008 New England Hand Society Physician Membership $150.00
2008 New England Hand Society Therapist/MLP/Nurse/PA Membership $100.00
* Your 2008 dues payment includes registration fee for the Society's Annual Meeting.
Please complete the information below and mail with payment made payable to the "New England Hand Society"
(please print/type)
First Name:
Middle Initial:
Last Name:
Practice Name:
Credentials :
MD OT OTR OTR/L
PT CHT COTA PTA
PAC PA Resident
Other (specify)

Office Address:
City:
State:
Zip:
Phone:
Fax:
NOTE: Please indicate the email address you would like listed in the online directory. If you do not want your email address listed in the directory, please indicate. Thank you!
Business Email Address:
Alternative Email Address:
Please choose one:
Business Email Alternative Email Please do NOT list Email
Practice Manager's Name:
Practice's Website Address:
Home Phone:
Check here if you do not want to receive Society information via your email

Remit payment by check and payable to:
New England Hand Society
c/o Susan Schaffman
26 Riggs Avenue
West Hartford, CT 06107

Pay by Credit Card :

For questions or comments, please contact Susan Schaffman, Administrator at (860) 561-5205 or email sasshops@aol.com.


Andrew E. Caputo, M.D.
President

David M. Bass, M.D.
Vice President

David Ring, M.D.
Secretary and Treasurer

Samuel Scott, M.D.
Membership Chairman

Mary Drake
Therapist Liasion