Tuesday, January 23, 2018
 

NJSHP’s Membership Dues Discount
Coupon Authorization Form
 
Date: ______________

 
New Member Name: ___________________________________

 
Recruiting Member Name: _______________________________________

 
Recruiting Member is:

 
_______ Pharmacist _________ Technician ____________ Other: _____________________________
 
specify

 
 

This is to authorize the issuance of a Membership Dues Discount Coupon to the above named Recruiting Member.

 
_______________________________
_____________________________
_____________________________
Chapter Officer Signature
Title
Chapter
 


Please attach this form to the Membership Application and forward them along with the dues payment to the Administrative Director


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