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FMAA
Membership Application 2008 |
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_______ Renewal |
_______ New Member |
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Name |
__________________________________________________________________________ |
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Street Address |
__________________________________________________________________________ |
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City ST ZIP Code |
__________________________________________________________________________ |
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Phone |
Home ___________________________ |
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Cell ____________________________ |
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E-Mail Address |
__________________________________________________________________________ |
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License Number |
__________________________________________________________________________ |
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Signature & Date |
__________________________________________________________________________ |
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Job Title |
__________________________________________________________________________ |
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Employer |
__________________________________________________________________________ |
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Address |
__________________________________________________________________________ |
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City ST ZIP Code |
__________________________________________________________________________ |
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Work Phone & Fax |
__________________________________________________________________________ |
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E-Mail Address |
__________________________________________________________________________ |
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Annual Dues: $25.00
Membership expires December
31st
of each calendar year. (Members will be included in the current year's membership directory if dues are received prior to March 1st.) Mail Membership application and check for $25.00 payable to FMAA to: |
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Susie Schlernitzauer
Integrated Medical Audit Specialists Inc.
13200 SW 128th Street, Suite B-3
Miami FL 33186 |
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Tell us in which committee you are interested in volunteering: |
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____ Bylaws ____ Conference |
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____ Newsletter ____ Membership |
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