NAME
                                        ADDRESS
                                        CITY 
                                        STATE       ZIP

                                        HOSPITAL/COMPANY 
                                        ADDRESS   
                                        CITY 
                                        STATE                      ZIP 

                                        FIELD OF SPECIALTY 

                                        TELEPHONE NUMBERS:

                                                 Home
                                                 Work
                                                 Fax 

                                        E-MAIL        
                                        WebSite/HomePage 

                    I'd be interested in the following (check all that applies):

Seminars
Lectures
Open Forums
Socials/Get-together

I'd be available for (check all that applies):

Membership Drive
Resource Speaker
Fund Raising
Program Scheduling
Public Relations

Comments/Additional information