PLEASE PRINT AND MAIL TO GENESEE COUNTY MEDICAL SOCIETY ALLIANCE TREASURER

Amita Desai

8171 Pine Hollow Trail

Grand Blanc, MI 48439

MEMBERSHIP YEAR: June 1 – May 31

TOTAL AMOUNT DUE: County $20 + MSMSA $32(Optional)+ AMAA 50 (Optional) = $102 if you choose to join all three.

If name & address corrections

Are needed, please enter below:

Name:___________________________

Address: ________________________

_______________________________

______________________________

Female/ Male

W Phone:

H Phone:

Fax:

Email:

County:

Member Type:

MSMS Alliance Member since (year):

Spouse Name:

County Alliance Member since (year): (full name)

Please make check payable to GCMSA

DUES AMOUNT

AMAA 50.00

MSMSA* 32.00

County 20.00

Total

*Please note if you are a spouse of a retired physician you can pay the reduced dues amount of $25.00 for STATE DUES ONLY!

For Your Records

Check # : ________________________

Check Date: ______________________

Check Amt: _______________________

MEMBERSHIP

Committee Chair: Lakshmi Tummala