Greenville County Medical Society Alliance

Membership Form

 

Name: ______________________________________________________________

Address:_____________________________________________________________

Phone: ___________________ Alternate Phone (i.e. cell): ____________________

E-Mail Address: _______________________________________________________

Spouse’s Full Name: _______________________ Preferred Name: _____________

Spouse’s Specialty/Group: ______________________________________________

Please note that some of the above information will be published in the

GCMSA Yearbook for Alliance use only.

Professional Background/Employment Status: ______________________________

Number of Children/Ages: ______________________________________________

 

Dues for:

GCMSA (County) $35 _____ SCMA Alliance (State) $25 _____

AMA Alliance (National) $50 _____

Total enclosed: $_____ 

 

Please make your check payable to GCMSA and return this form to:

 

Aimee Lonergan

406 Chancery Lane

Simpsonville, SC  29681

 

Thank you for your continued support of the GCMSA.

.

Treasurer Use Only:

Check Number:____                                                                   Date Deposited:_______

Greenville County Medical Society Alliance