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Vermont/New Hampshire

Cytotechnology Association, Inc.

MEMBERSHIP APPLICATION

Name:

Home Address:

Home Phone: (

)

-

Work Address:

Work Phone: (

)

-

E-Mail Address:

Type of Membership:

Cytotechnology Member (CT, MD, Other)

$10.00

Student Member

$ 5.00

Donation

$

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Mailed newsletter

Dues are payable each year on January 1. Please make checks payable to: VT/NHCA

Please send payments to:

Amy Verville, Treasurer, VT/NHCA

Fletcher Allen Health Care

Cytopathology Department

111 Colchester Ave – Smith 271

Burlington, VT 05401