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| Michael S. Clark, M. D. -Secretary-Treasurer |
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| Annual Dues: _____________________________________$100.00 |
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| SMCAF Education Fund __________________________________________ |
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| Please make check payable to SMCAF |
Total: __________ |
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| Address Correction: __________________________________________ |
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| AMA Member |
Yes _____ |
No _____ |
Specialty: __________ |
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| The Society of Medical Consultants to the Armed Forces |
| 5 Southern Way |
| Fredericksburg, Va. 22406 |
