Membership Registration

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?*

Yes

Please let us know your group*

If other, please mention

Where did you hear about us?*

Please elaborate

Professional Information

Organization

Website (Start With: "http://")

Office Phone

Are you a Group Member?*

Yes

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.