Print this out, fill it out and mail it to Judy.
Washington Society for the History of Medicine
Membership Form 2008
NAME: ___________________________________________________________
ADDRESS: ________________________________________________________
CITY: _____________________________________________________________
STATE: _________________________ ZIP CODE: ___________________
TELEPHONE: ____________________________Work_____ or Home_____
EMAIL ADDRESS: __________________
AFFILIATION: ____________________________________________________
MEMBERSHIP CATEGORIES:
STANDARD: $15.00 __________
SPONSOR: $25.00 __________
STUDENT: $10.00 __________
Dear WSHM Member
Please make your checks payable to the WSHM. Mail your membership dues and this form to: Judy M. Chelnick, Secretary-Treasurer, WSHM, 4868 Cloister Drive, Rockville, Maryland 20852 Thank You!
Check out our Website: http://wshmdc.blogspot.com/
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