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Mail-in Membership Renewal |
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Use this form to renew your membership by mail
NEW MEXICO SOCIETY OF ANESTHESIOLOGISTS 7770 Jefferson NE, Suite 400 Albuquerque, New Mexico 87109
Telephone: (505) 828-0237
Physician Name, MD
Physician Address
City, State Zip
January, 4, 2007
Please pay as soon as possible STATUS AMOUNT 2007 MEMBERSHIP DUES Active $150.00
Affiliate $ 75.00
AA $ 75.00
Resident None
Retired None
To be a member of the American Society of Anesthesiologists, you must also be a member of the New Mexico Society of Anesthesiologists Please make checks payable to: NMSA. If you wish to pay by credit card, please go to the website – www.nmsahq.org. If you are retired, could you please return the form to us if you wish to remain a retired member, even though no money is due.
Return this form with your payment to the above address. Your cancelled check is your receipt. We would like to do as much corresponding by email as possible – please fill in your email address, if you have one, below. NAME: _____________________________________ E-MAIL: _______________________________________________
STATUS: ______________________________________________
Indicate any changes such as address, status, etc., below:
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