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| Michael S. Clark, M. D. -Secretary-Treasurer |
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Annual Dues: __
Active Member $50.00__Associate Member $40.00 $ _____________
(associate
members = active duty) |
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SMCAF Education
Fund ________________________________ $ญญญญ_____________
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make check payable to SMCAF
TOTAL $ ____________ |
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| Address Correction:
____________________________________________________ |
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| E-mail Address: ________________________________________________ |
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| Current AMSUS Member: Yes __________ No__________
SMCAF members must become AMSUS members by January 1, 2011.
If you are not an AMSUS member, do you intend to join?
Yes __________
No __________ I wish to resign my membership in SMCAF.
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| AMA Member |
Yes _____ |
No _____ |
AMA Member number ____________ |
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| The Society of Medical Consultants to the Armed Forces |
| 5 Southern Way |
| Fredericksburg, VA 22406 |
