Subscription form

* Mandatory fields
Profile Picture
In this field, you may upload a profile picture. Maximum size: 110 x 110 pixels. Larger images will be resized.
*First name
Middle Name
If you would like to add your Middle Name, you may do so. However, this is not a mandatory field.
*Last name
Credentials
If you would like your credentials on your membership card, please type them here.
*Organization
List the hospital, institution, and/or organization that you belong to. If you are a Student Member, please list the Educational Institution that you belong to.
*E-mail
Please list the e-mail that you use most frequently. This will be the e-mail where important NYSSRS information will be sent.
*Phone
*Street Address
*City
*State
*ZIP Code
Program Director
Educational Institution
Program Phone #
Continuing Education
You can upload up to 20 files. Each file should be less than 20 MB.
 

NYSSRS, Inc. is a 501(c)6 non-profit organization. PO Box 302/ Centereach, New York 11720-0302

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