The Nassau Pediatric Society Application
 

 

Name: __________________________________________ Date of Birth________________________________	Mail to: ____ Office              ____ Home
Office: Address _____________________________________________________________________________ Phone ________________   Fax___________________    e-mail ________________________________   Home: Address _____________________________________________________________________________ Phone ________________   Fax___________________    e-mail ________________________________
Type of Membership Applied for: Regular:($155) _____	Resident: ($75) _____
Dues (Must be enclosed): $ ___________________

EDUCATION:

	Dates
College: ___________________________________________________	_____________________________________
Medical School: _____________________________________________	_____________________________________
Post Graduate Training: _______________________________________	_____________________________________
Hospital Affiliations: __________________________________________	_____________________________________
Board Eligibility: _____________________________________________	_____________________________________
Board Certification: ___________________________________________	_____________________________________
F.A.A.P. -                                      Yes _____ Date: _________________	No _______
Member of New York State Medical Society -                        Yes _____	No _______
Type of Practice - Subspecialty: ______________________________                             General Pediatrics: __________________________

Sponsor(s)__________________________________________________________________________________________
 

I hereby apply for membership in the Nassau Pediatric Society. ________________ Date

__________________________________________ Signature

Please forward application to the Membership Chair
Anthony Battista, M.D., F.A.A.P
1101 Stewart Avenue, Suite 306
Garden City, NY 11530