UWHA Membership Application 2018
A $6 monthly membership fee will be automatically deducted from your paycheck.

If your department is Family Medicine, please pay your annual membership fee of $72 via PayPal (mail@uwha.org) or mail a check to the following address:

UW House Staff Association
PO Box 45373
Madison, WI 53744

For more information about UWHA, check out our website at www.UWHA.org

First Name *
Your answer
Last Name *
Your answer
Hospital ID number
i.e. the numbers on the back of your badge (if you're new to UW and do not have your hospital ID number yet, leave blank)
Your answer
Department *
Email Address *
Your answer
UWHA Membership Statement and Authorization of Dues Deduction *
By submitting this form, I certify my intent to be a member of the University of Wisconsin House Staff Association (UWHA). I hereby authorize the University of Wisconsin Hospital and Clinics to deduct from my monthly salary check, the amount of $6.00 for dues payable to UWHA. If my department is Family Medicine, I will mail or pay via PayPal my annual dues in the amount of $72.00.
Significant Other's Email Address
If you have a significant other who is interested in receiving complimentary updates from UWHA regarding social events etc., please provide his/her email address:
Your answer
Do you have a significant other who would like to join the Significant Other Society?
Annual dues of $16 for new members, $8 for returning members
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