MEMBERSHIP APPLICATION SOUTHERN ILLINOIS MEDICAL ASSOCIATION

(Please PRINT or TYPE)

NAMEDEGREE
HOME ADDRESS

_ZIP CODE_
HOME PHONE NUMBER(_)
OFFICE ADDRESS
________
_ZIP CODE_
OFFICE PHONE NUMBER(_)________
SPECIALTY_
SOCIAL SECURITY NUMBER___________
DO YOU PREFER TO HAVE LETTERS, PROGRAMS, AND DUES STATEMENTS MAILED TO YOUR HOMEOR OFFICEADDRESS? (PLEASE CHECK ONE)
ANNUAL DUES ARE $25/year for Physicians, Physician Assistants, Nurse Midwives, & Nurse Practicioners
MAIL APPLICATION AND CHECK TO:

Southern Illinois Medical Association

Dale H. Rosenberg, M.D.-Executive Secretary-Treasurer

c/o Betty Burkhart, CMA

74 Dale Allen Drive

Belleville, IL 62226-5725

SIGNATURE_________________________________________________________________

DATE________________________________________

SIMA Internet Homepage http://www.omegabbs.com/users/SIMA