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Subscriber Services Application
THE NEW YORK ACADEMY OF MEDICINE 1216 Fifth Avenue
New York, New York
10029-5293

tel: (212) 822-7296
fax: (212) 722-7650

Division of Library & Information Resources
Information Services Department

 

Subscriber Services Application

 

Company Name__________________________________________________

Contact Name___________________________________________________

Address________________________________________________________

City________________________ State _______ Zip __________________

Telephone_________________________Fax__________________________

Billing Contact Name:______________________________________________

Billing Address___________________________________________________

City________________________ State _______ Zip __________________

What type of organization or business are you?_______________________

Approximate number of employees with your firm?_____________________

Please list on the reverse side, names of staff and their phone numbers (if different) who are authorized to use the service.

We acknowledge the following terms and conditions of this agreement:

All work performed by Subscriber Services will be done in a confidential manner.

While Subscriber Services attempts to provide accurate information, it makes no warranties, and disclaims any liability for loss or damage to any party caused by errors or omissions or statements of any kind.

Billing will be made on a monthly basis.

Please enclose a check in the amount of $1,400. The prorated fee is $120 per month, please enclose your check in the amount of $_______, for service beginning / / ). This represents a pro-rated amount of the $1,400 annual membership fee for organizations doing business with The New York Academy of Medicine Library Subscriber Services. Please indicate to whose attention the monthly invoices are to be mailed.

Name___________________________________________________________

Mail to: Subscriber Services

The New York Academy of Medicine Library

1216 Fifth Avenue

New York, New York 10029-5293

Name of Applicant____________________________________________

Title____________________________________________________________

Signature___________________________________Date_________________