Medical Staff Dues

Comments
This field is for validation purposes and should be left unchanged.
Authorization Code*
Note: Do not change the Authorization Code.
Note: You cannot submit this form without the correct authorization code. For the code, please contact the Medical Staff Office.
Your Name*
First Last
Phone*
Email*
I am:*
- A Medical Staff Member
- An Office Manager
Note: Due amounts are determined by medical staff status. Please note the names of the medical staff member(s) you are paying for in the available box below and select the applicable quantities for each medical staff status. Medical staff statuses are listed on the individual dues invoice(s).
Note: Due amounts are determined by medical staff status. Please put a quantity of 1 in the box of your current status as noted on your dues invoice.
Medical Staff Member Name(s)*
Active Staff Quantity
Price: $350.00
Courtesy Staff Quantity
Price: $200.00
Allied Health Professional Quantity
Price: $50.00
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Comments or Special Instructions
Note: An emailed receipt will be sent to you upon submission.
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