Membership Form
* Denotes required field
*Type of Membership:
FTIR ($300/Location) Type of FTIR Instrument
Raman ($300/Location) Type of Raman Instrument
Total Cost $0.00

My Information:
*First name
*Last name
*E-mail
*Job Title
*Lab/Agency Name
*Lab/Agency Address
Line 2 (Optional)
*City
*State   *Postal Code
*Phone Number () -
Alternate Phone Number () -

Address to Ship PT Samples:
*Lab/Agency Address
Line 2 (Optional)
*City
*State   *Postal Code

*My method of payment is:
  PO Number:
  Credit Card
  Pay with a check (Check Number: )

Billing Address:   (If paying through a PO Number...)
Address
Line 2 (Optional)
City
State   Postal Code
Make checks payable to "The Nebraska Medical Center/NPHL"
and mail your payment to:

Attn: David Moran
NPHL, DRCII 8th Floor
985900 Nebraska Medical Center
Omaha, NE 68198-5900

Type the text on the left
into the space below.
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Steven H. Hinrichs, M.D., Director
David Moran, MT (ASCP), Program Coordinator
Nebraska Public Health Laboratory 		985900 Nebraska Medical Center
Omaha, NE 68198-5900
Phone: (402) 559-9421
Fax: (402) 559-7799