New Jersey Society for Histotechnology

New Jersey Society for Histotechnology

P.O. Box 6792

Lawrenceville, NJ 08648

2016-2017 Membership Application

(Please print or type)

Name: ______Home Phone: ______

Home Address: ______

City: ______State: ______Zip: ______

Place of Employment: ______

Department: ______

Work Address: ______

City: ______State: ______Zip: ______

Work Phone: ______Fax: ______E-Mail: ______

Send mail to: Home Address ____ Work Address ____ Include me in the NJSH Directory: Yes ____ No ____

Please Check All That Apply:

Membership: / Certification/Degree: / Type of work place:
NJSH Renewal / ____ / HT(ASCP) / ____ / University / ____
NJSH New Member / ____ / HTL(ASCP) / ____ / Hospital / ____
NJSH Student Member / ____ / AS / ____ / Private Lab / ____
NSH Member / ____ / BS / ____ / Veterinary / ____
MS / ____ / Pharmaceutical / ____
ASCP Member / ____ / PhD/MD/DVM / ____ / Sales/Service / ____
Species: / Special Tissues: / Tissue Preparation Techniques:
Human / ____ / Hard Tissue / ____ / Paraffin / ____
Animal / ____ / CNS Tissue / ____ / Plastic / ____
Insects / ____ / Eyes / ____ / Frozen / ____
Plants / ____ / Biopsies / ____
Special Procedures:
Enzyme Histochemistry / ____ / Confocal Microscopy / ____ / Perfusion / ____
Immunohistochemistry / ____ / TEM / ____ / Exfoliative Cytology / ____
In Situ Hybridization / ____ / SEM / ____ / MOHS / ____
Autoradiograpy / ____ / Molecular Techniques / ____ / LCM / ____
Image Analysis / ____ / Microwave Techniques / ____

Annual dues (June 1 – May 31) are $10.00. Dues for all full time students are $5.00. Dues are waived for retirees. Remit fee with application to address above.

Please make check payable to NJSH.

For NJSH Use:

Date Received: ______

Amount: ______

Check Number: ______