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NYSSMOH CORPORATE MEMBERSHIP PROGRAM 2009
Tax I.D. #13-3728930
Date: _________________________________
Company: _________________________________
Contact Name: ________________________________
Contact Title: _________________________________
Address: __________________________________
__________________________________
Tel #: _______________
Fax #: _______________
Email: _______________
_____ Yes – we will participate in the NYSSMOH Corporate Membership Program for
2009.
_____ No – we will not participate in the NYSSMOH Corporate Membership Program
for 2009.
CORPORATE MEMBERSHIP _____ $10,000
Please return to:
Florence Madonia, Executive Director
64 Cascade Road
Warwick, New York 10990
Tel: 845-986-3295
Fax: 845-986-3336
e-mail: fmbilling@yahoo.com
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