VMGMA Membership Application

Memberships are individual and non-transferable. Your membership will be in effect until 12/31/11.

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* Full Name:
* ACMPE Certification:	Select One None Nominee CMPE FACMPE
* Title:
* Organization:
* Street Address:
* City, State, ZIP Code:
* Phone Number:
FAX Number:
* Email address:
* How did you hear about the VMGMA?	Select One Current Member Colleague Co-Worker Mailing VMGMA Conference National Member Other
If referred by VMGMA member, please include their name:
Years in medical management:
* Practice Specialty:	Select One Dermatology ENT Gastroenterology Multi-Specialty OB/GYN Opthalmology Orthopedics Neurology Primary Care Pediatrics Pulmonary Urology Surgery Other
* Practice Size:	Select One Small (1-4 Providers) Medium (5-11 Providers) Large (12+ Providers)
Yes! Please notify me by email about special events, promotions, and other materials
* Items required to submit form