Document 6599797

To apply for membership, please print both pages, fill them out and submit them via email, fax or mail
2015 Alaska State Medical Association (ASMA)
Update your information for the 2015 Directory
4107 Laurel Street, Anchorage, AK 99508  (907) 562-0304  (907) 561-2063 (fax)  [email protected]  www.asmadocs.org
Information update is due by Nov. 30th 2014 to ensure placement in the 2015 Printed Directory.
Date: _________________________
Name (first, middle, last):
. Degree(s): MD / DO
Specialty(ies): _______________________________________________________________________________________
NPI #:
AK License #:
Published Email: _______________________________
Date of Birth:
.
Member Email: __________________________________
Practice Type: please circle one
Private
Contract Hire/Employee
Administrative
Locum Tenens
Public Health
Military
Retired
Inactive
Clinic Name:
.
Clinic Address, City, Zip:____________________________________________________________________________________
Office Phone:
Office Fax: ______________________________
Website:
.
Member Address: ____________________________________________________________________________________________
Member Phone: _________________________________
Member Fax: __________________________________
Additional Practice Locations:
___________________________________________________________________________________________________________
Board Certification(s) – American Board of Medical Specialties or American Osteopathic Association Specialty Boards ONLY:
.
.
Medical School:
Graduation Year:
.
.
After submitting this form, you may update your information at any time via ASMA’s website, www.asmadocs.org. Click “Update
Your Information.” Changes will be reflected in the Online Medical Directory within a few days, so your information is always upto-date!
Submit your member photo for the directory to [email protected]
PLEASE SEE NEXT PAGE FOR IMPORTANT MEMBERSHIP INFORMATION
Membership Application
Alaska State Medical Association Dues
(ASMA)
Local Medical Society Dues
(LMS)
Annually
$650
325
50
25
200
Call
Call
Regular Member
1st Year New Member
Residents
Medical Student
Associate/Retired
Semiretired
Group Membership
Anchorage (AMS)
Fairbanks
Juneau
Kachemak Bay
Kenai Peninsula
Ketchikan
Matanuska-Susitna
Sitka-Mt. Edgecumbe
Annually
100.00
Collected Locally
Collected Locally
Collected Locally
Collected Locally
Collected Locally
Collected Locally
Collected Locally
Payment Summary:
ASMA Dues $
.
LMS Dues
$
.
Total Dues
$
.
ASMA no longer offers Automatic Renewal or Quarterly Payment Options. All membership dues must
be received by November 30th to ensure proper placement in the 2015 Printed Medical Directory. We do
not accept credit card numbers over the phone; please fill out the form completely and legibly or we will
be unable to process your membership.
Credit Card Authorization: Now accepting all major credit cards
Total to be charged: $
Credit Card #:
.
-
-
-
. Expiration Date:
. CVS Code_________
Name (Please PRINT name as it appears on card):
Billing Address for CARD:
.
Billing Address MUST INCLUDE ZIP CODE:
Phone:
.
Email you’d like credit card receipts sent to: ________________________________________________________________
The issuer of the card identified above is authorized to pay the amount shown as “Total to be charged”. I promise to pay the amount
“Total to be charged” subject to and in accordance with the agreement governing the use of such card.
Date:
.
Signature (required): ______________________________________________________
ASMA dues are not deductible as a charitable contribution for federal income tax purposes but may be partially deductible as an
ordinary and necessary business expense. 16% of ASMA dues are not deductible as an ordinary and necessary business expense,
because this portion of dues is attributable to lobbying activities. Your ASMA membership includes subscriptions to the Alaska
Medicine, Heartbeat and two copies of the Medical Directory (one printed and one electronic) at no charge. ($20 of your member dues
is allotted for Alaska Medicine, $15 for Heartbeat and $140 for the Medical Directories.)