Brooklyn Pediatric Society

Membership Form

Executive Officers  2012-2013: 
 Levon Agdere, MD
Leslie Hayes, MD, 
Danthanh Hoang, MD
Elana Altzman, MD, Past President 
Leslie Alvarado, MD, Past President 
Roger Kim, MD, Past President 

Nitin Ron, MD, Past President
Mary Gallagher, Administrator

Name

Office Information

Address:
Telephone: Email:
Fax: Website:

Personal Information

Home Address

Telephone:                                         Email:

Education

College:

Medical School:

Training

Internship:

Residency:

Fellowship:
Board Certification Board: Date:
Subspecialty: Date:
Hospital Affiliations 1. 

2.
Society Memberships 1.

2.
References 1.

2.

Comment:

_____________________________________                                       ____________

Signature                                                                                                    Date

Annual membership dues are Regular $150,    Retirees $75,    and   Fellows/Residents $50. 

Please submit your check with the completed application to:   Brooklyn Pediatric Society  

New York Methodist Hospital,,   Dept of Pediatrics,  506, 6th Street,    Brooklyn NY 11215