MEMBERSHIP APPLICATION SOUTHERN ILLINOIS MEDICAL ASSOCIATION

(Please PRINT or TYPE)

NAME____________DEGREE
HOME ADDRESS
_
_ZIP CODE_
HOME PHONE NUMBER(_)_______________
OFFICE ADDRESS_
_________________
_ZIP CODE_
OFFICE PHONE NUMBER(_)____________
SPECIALTY_
E-MAIL ADDRESS_____________________________
DO YOU PREFER TO HAVE LETTERS, PROGRAMS, AND DUES STATEMENTS MAILED TO
YOUR HOMEOR OFFICEADDRESS? (PLEASE CHECK ONE)
ANNUAL DUES ARE $30/year for Physicians, Physician Assistants, Nurse Midwives, & Nurse Practicioners
MAIL APPLICATION AND CHECK TO:

Southern Illinois Medical Association

Kathy D. Swafford, M.D.-Executive Secretary-Treasurer

115 N. Main St.

Anna, IL 62906

SIGNATURE____________________________________________________________________________

DATE__________________________________________________________________________________

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