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Alabama Osteopathic Medical Association

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					          Alabama Osteopathic Medical Association
                                      2009 Dues Statement
Phone (205) 487-3625                                                             200 Carraway Drive, Suite 1
Fax (205) 487-7559                                                               P.O. Box 1857
www.aloma.org                                                                    Winfield, AL 35594
_____________________________________________________________________________________________________________

Preferred Contact   Name___________________________________________________

Information   Address_________________________ AOA #____________________

              City, State___________________________________________________

              Zip____________________________ Phone_______________________

              Email____________________________ Year Graduated____________

           Medical School________________________ Specialty_______________
Category                           Fee         Amount Paid
Regular Active Membership          $300        ___________
Out of State                       $150        ___________
Active Military                    $50         ___________
Student/Resident/Intern            $0          ___________

   Pro-Rated (first 4 years of practice upon completion of residency)
First Year Active Practice 25%                 $75            ___________
Second Year Active 50%                         $150          ___________
Third Year Active 75%                          $225          ___________
Fourth Year Active 100%                        $300          ___________

Retired (Retirement Date___________)               $150            ___________

                                          Total Enclosed ___________
Visa _________________             MasterCard __________________ Check #________

Name as it appears on Credit Card______________________________________

Credit Card #_________________________ Exp. Date____________________

Signature ________________________________________________________

                                       Upcoming Meetings
                             19Th Annual Emerald Coast Conference
                                        July 19 – 22, 2009
                                   Sandestin Hilton, Destin, FL
                    (850) 267-9500 or (800) 367-1271 Conference Code: AOM
                              Contact Dr. Jim Nabers (256) 356-9537
                                   Email: jamesn@hiwaay.net

				
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