WCMSA Membership Form
We are so glad you're joining us!

By filling out this form, you agree to be invoiced for your membership via PayPal. You will be invoiced a small transaction fee for online payment.

If you prefer to submit a check and paper form, you can fill out our PDF application here: http://wcmsa.org/wp-content/uploads/2015/11/wcmsaap2012.pdf

Member First Name *
Your answer
Member Last Name *
Your answer
Member Email Address *
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Member Preferred Phone
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Street Address
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City
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State
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Zip
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Which member dues should we bill you for?
Please note that we may add a small fee to cover the transaction costs charged by the credit card processor.
Which optional contributions would you like to make?
These contributions are sent to the state (IMPAC) and national (AMPAC) political action committees that lobby for pro-physician candidates and legislation.
Spouse First Name
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Spouse Last Name
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Spouse Email
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Spouse Preferred Phone Number
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Member Notes
Please indicate your information and preferences below.
Physician Member Specialty
If you are applying for membership and you are also a physician, please note your specialty here.
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Spouse Specialty
If your spouse is a physician, please note your spouse's specialty here.
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Questions or Comments
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