Medical School________________________ Specialty_______________
CategoryFeeAmount Paid
Regular Active Membership$300___________
Out of State$150___________
Active Military$50___________
Student/Resident/Intern$0___________
Pro-Rated (first 4 years of practice upon completion of residency) First Year Active Practice 25%$75___________ Second Year Active 50%$150___________ Third Year Active 75%$225___________ Fourth Year Active 100%$300___________ Retired (Retirement Date___________)$150___________
Total Enclosed___________
Visa _________________MasterCard __________________ Check #________
Name as it appears on Credit Card______________________________________
