Application for Affiliate Membership / 2011-2016 Middle Atlantic Region

Membership Description:

• Can be any library, information/resource center, or organization that is called upon for health information by its users
• Public libraries are encouraged to join as Affiliate Members
• Affiliate Members do not participate in DOCLINE, the interlibrary loan system
• Affiliate Members may form a cooperative relationship with a Full Member for reference assistance or document delivery

Institution Name: *

Library Name:

Mailing Address: *

City: *

County: *

State: * Choose DE NJ NY PA

Zip Code: *

Phone: *

Institution Website:

Library Type: * Choose One Hospital Academic Public Other / Not a Library (see below)

If Other / Not a Library, describe:

Designate an individual as your NN/LM Liaison who will be responsible for communication of MAR activities to your institution.

NN/LM Liaison:

First: * Middle Initial: Last: *

Position Title: *

Email: *

Phone: *

Fax:

Additional Contact Person (optional):

First: Middle Initial: Last:

Position Title:

Email:

Phone:

Fax:

Additional Contact Person (optional):

First: Middle Initial: Last:

Position Title:

Email:

Phone:

Fax:

After submitting this form, you will be contacted by NN/LM Middle Atlantic Region (MAR). 
If you have any questions regarding this form, please contact MAR at (800) 338-7657 or nnlmmar@pitt.edu.