OREGON GERIATRICS SOCIETY      Annual Membership Dues 2011 (January 1, 2011 – December 31, 2011)   Doctoral and Master’s Prepared Health Care Providers:               $75.00 Other Health Care Providers:                                                            $40.00 Health Care Professionals in Training/Students:                              FREE *DUES MUST BE PAID BY JULY 1, 2011,  TO BE ELIGIBLE FOR THE ANNUAL CONFERENCE “MEMBER RATE” In order to process your membership information please supply the following – or attach business card.  ALL FIELDS REQUIRED   NAME (First, Middle Initial, Last):_____________________________________________________ PROFESSIONAL DEGREE (MD, RN, etc.):____________________________________________ COMPANY NAME (Hospital, Clinic, Etc.) _____________________________________________ COMPANY TITLE (Pres, Med Dir, Etc.):______________________________________________ STREET ADDRESS:______________________________________________________________ CITY, STATE, ZIP CODE: _________________________________________________________ TELEPHONE:________________________ CELL:________________________ FAX:___________________________ EMAIL ADDRESS:______________________________________________________________ Check Enclosed: ____ Credit Card: ____ (circle one): VISA, Mastercard, Discover Name on Card (required):__________________________________________________________ Address of Card Holder:___________________________________________________________ City:_______________________________ State:________ Zip Code (required):_______________ Card Number (required):______________________________________ Exp Date (required):______

 

Remit Payment and Dues Form to Oregon Geriatrics Society

Mary Olhausen, Executive Director - Oregon Geriatrics Society
2310 NE 77th Avenue, Vancouver, WA 98664

QUESTIONS:
Mary Olhausen, omary52@comcast.net
Call: 360-892-1814
FAX: 360-326-1844

Please print this form for your receipt.

Thank you for your support!!