Association of Physicians of Pakistani Descent of North America - New Jersey Chapter
Membership Form

APPNANJ PICNIC 2009
REGISTRATION FORM

Full Name:*
Number of Attendes:
Adults:* (Membership fees applied - Please select Membership type below)
Children (11-15 years): ($45 per child - After 6/15/09)
Children (5-10 years): ($35 per child - After 6/15/09)
Children (Under 5 years): ($0.00 per child)

Address:*

Home Phone:

Cell Phone:
Email:*
Tickets:* APPNANJ Lifetime Members - $40 (After 6/15/09)
APPNANJ Member Physicians - $50 (After 6/15/09)
APPNANJ Non- Member Physicians - $60  (After 6/15/09)
Physicians in Training - $45 (After 6/15/09)
captcha image
Total fee: $ 
 
After you have submitted the information in the form above, please click on the button given below to make payment. Registration will not be complete without payment. Thanks!
Alternatively, you can mail the check to :

APPNA-NJ
404 Blanch Ave.
Closter, NJ 07624
Copyright © 2005-2008 APPNA New Jersey. All Rights Reserved.
Designed and maintained by Muffice