Lansing Guild of the CMA

Membership Application Form

The following form will create a page that you can print and send in to the following address:

Lansing Guild of the Catholic Medical Association
P.O. Box 356
Ann Arbor, MI 48106-0356

Or Fax to (734) 930-7484

Thank you for your support of this ministry!

I wish to apply for membership in the Lansing Guild of the CMA

Physician member ($50)
Retired physician member, other health care member, general public ($25)
Medical student, resident, clergy (FREE)
Mailing list only ($15)

All dues/contributions are tax deductible under section 501(c)(3) of the IRS code.
Name:
Degree:
Specialty:
Address:
City:
State:
Zip:
Telephone:
Fax:
Email:
Referred By:

	Health Care professional memberships will receive complimentary choice of:
		Hippocratic Oath (framable 81/2 x 11" from the National Catholic Bioethics Center)
		St. Camillus red cross pin and booklet.
For additional contributions of $100 or more, we will send one of our outstanding presentations on CD.

Dues Enclosed
Contribution
Total
Pay By	Check - Payable to "CMA - Lansing Guild" Other If Other Please Specify