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 Membership Details
First Name*:
Last Name*:
Email*:
Office Address*:
Address cont.:
City/Town*:
State*:
Postal Code*:
Country:
Office Email:
Mobile (ex. 5551111212)*:
Degree (ex. MD. DO, PhD, etc.)*:
Specialty*:
QME?*:
 Professional Information
Organization:
Website (Start With: "http://"):
Office Phone:
Are you a Group Member?*:
If Yes, Group Name (If No, write NA)*:
Group Manager Name (If No, write NA)*:
Group Manager email (If No, write NA)*:
# of Group Members (If No, write NA)*:
 Payment Note
 For payment by Check - Please make check payable to CSIMS and mail it to: Attn: Dr Goldstein, CSIMS Headquarters, 3000 W. MacArthur Blvd Suite #600, Santa Ana, CA 92704.
 Payment Method
Payment By :
Name On Card :
Membership Amount :
Total Amount :
Check No. :
Check Issue date :
Name of issuing bank :
 
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