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North Carolina Chapter
American Academy of Pediatrics
North Carolina Pediatric Society
Membership Application for Practice Managers
Name ______________________________________ Degree________
Date_________________
Practice Name
_________________________________________________________________
Practice Address
_______________________________________________________________
City
_________________________________ State ________ Zip
_______________________
Practice Telephone
_____________________________________________________________
Practice Fax
___________________________________________________________________
Home Telephone
(Optional) ______________________________________________________
E-Mail Address
________________________________________________________________
Send completed Application Form with a check
(please do not combine check with membership-dues for pediatricians)
in the amount of $50.00 payable to NCPS for Annual Membership Dues.
North Carolina
Pediatric Society
1100 Wake Forest
Road, Suite 150
Raleigh, NC 27608
Phone: 919/ 839-1156 Fax: 919/839-1158
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