1997 Membership Application and Address Update Form

(Print out and complete this page and send it in along with annual NAS dues and/or registration fees)

Name:________________________________________________________________________________________
_______________________________________________________________
(circle one) Active Duty Reserves Retired Civilian
Street & Apartment #:____________________________________________________________________________
City, State, Zip Code, Country:_____________________________________________________________________
Email Address: __________________________________
Home Telephone #: (______)____________________
Work Telephone #: (______)__________________________
Fax #:(______)______________________________
How did you hear about the Navy Anesthesia Society? (circle all that apply)
Direct Email/NAS Newsletter/Colleague/Web Page/Internet (specify discussion group or site): __________________________
Other (specify): _________________________________________________________________________________
Comments (continue on reverse if necessary):


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1997 NAS Fall Update Registration and Dues Remittance Form NAS Fall Update # attending _____ @ $50 =$

NAS Banquet # attending _____ @ $40 =$

1997 NAS Annual Dues (credentialed anesthesia providers)# ____________ @ $25 =$

1997 NAS Annual Dues (all others)# ____________ @ $10 =$

Tax-Deductible Gift Donation to the NAS: =$

(The NAS most gratefully accepts your generous donations---no matter how small---to help us stay afloat!)

TOTAL AMOUNT ENCLOSED =$

Did you know?: All gift donations to the Navy Anesthesia Society and Annual Dues in excess of the first $10 are deductible on IRS Form 1040, Schedule A---Itemized Deductions!

Please make check or money order payable to the order of the Navy Anesthesia Society. Send this form along with your check to :

The Navy Anesthesia Society
c/o LCDR David G. Elkins, MC, USN
Department of Anesthesiology
Naval Medical Center
San Diego, CA 92134-5000