WCMSSM Alliance Application - Wayne County Medical Society of Southeast Michigan

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To apply for a WCMSSM Alliance Membership, please complete the form below.

Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Home Phone

FAX

E-mail

Occupation/Profession

Spouse's Name

Phone

Spouse's Specialty

Select your membership choice(s)

	Wayne County Medical Society of Southeast Michigan Alliance $20
	Michigan State Medical Society Alliance $32
	American Medical Association Alliance $40
	Join all three $92

Click 'send to WCMSSM" to submit this form electronically.

This section to be mailed only:

Charge to:
Expiration Date:
Account #:
Signature:

Make checks payable to the WCMSSMA and mail to:

Wayne County Medical Society of Southeast Michigan Alliance
Rita Talamonti, Alliance Treasurer
3031 West Grand Blvd. Suite 645
Detroit, MI 48202

To charge fax form to Executive Secretary at 313-874-1366

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