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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 none, write 0)*:
 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.
Please let us know your group*:

If Other, please mention:
 Group categories include- Group 1: (MD. DO, DC, DPM, DDS, Ph.D, Psych.D,) Group 2: (NP, PA) Group 3: (Attorney/Legal, Nurse case manager) Group 4: (Insurance adjuster. Billing and Collection, Pharmaceutical, Consulting)
Where did you hear about us?:*:

Please elaborate:
 Payment Method
Payment By :
Name On Card :
Membership Amount :
Total Amount :
Check No. :
Check Issue date :
Name of issuing bank :
 
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