Applicant Name

Company

Address

City State Zip

E-mail Address (necessary for delivery of newsletter)
Telephone Number and Area Code

National Membership $125 Gold Membership $195 Platinum Membership $215
Associate Membership $95
Associate Applicants-Enter name of sponsoring member here:

NOTE: Print this page and send with check payable to EMBN to:
Electronic Medical Billing Network of America, Inc.
51 Eton Court, Bedminster, New Jersey 07921
Phone 908-470-4100 FAX 908-470-4233

Email: merl@medicalbillingnetwork.com

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Major charge cards accepted
For faster service, use your credit card. Fill out the additional information below, print this page and fax to:
908-470-4233

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American Express Master Card Visa

Card Number

Date of Expiration

Name on Card

NOTE: Print this page and mail with check or fax with above credit card info to:

Electronic Medical Billing Network of America, Inc.
51 Eton Court, Bedminster, New Jersey 07921
Phone 908-470-4100 FAX 908-470-4233
Email: embn@medicalbillingnetwork.com
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