Michigan Association of Osteopathic Family Physicians

Membership Application

2015

Please submit application and payment (if applicable) to the address below.

Michigan Association of Osteopathic Family Physicians

2123 University Park Drive, Suite 100 Okemos, MI 48864

Phone 888-204-9124 Fax 517.708.7250

www.maofp.org

Member Type (Check One):

Please submit application and payment (if applicable) to the address below.

Michigan Association of Osteopathic Family Physicians

2123 University Park Drive, Suite 100 Okemos, MI 48864

Phone 888-204-9124 Fax 517.708.7250

www.maofp.org

Please submit application and payment (if applicable) to the address below.

Michigan Association of Osteopathic Family Physicians

2123 University Park Drive, Suite 100 Okemos, MI 48864

Phone 888-204-9124 Fax 517.708.7250

www.maofp.org

r First Year Physician ($50)

r Physician ($175)

r Associate – FP Outside MI ($175)

r Affiliate – Degreed healthcare professional ($175)

r Retired ($0)

r OMS I ($0)

r OMS II ($0)

r OMS III ($0)

r OMS IV ($0)

r RES I ($0)

r RES II ($0)

r RES III ($0)

r RES IV ($0)

Please submit application and payment (if applicable) to the address below.

Michigan Association of Osteopathic Family Physicians

2123 University Park Drive, Suite 100 Okemos, MI 48864

Phone 888-204-9124 Fax 517.708.7250

www.maofp.org

Please submit application and payment (if applicable) to the address below.

Michigan Association of Osteopathic Family Physicians

2123 University Park Drive, Suite 100 Okemos, MI 48864

Phone 888-204-9124 Fax 517.708.7250

www.maofp.org

Status (Circle One): Certified FP FP N/A Other______

AOA #: Birth date: Sex (Circle One): F M

First Name: Last Name:

Degrees, Credentials: ______

Mailing Address:

City: State: Zip:

Phone: Fax:

Email: Website:

College: Date of Graduation:

Hospital Affiliation:

METHOD OF PAYMENT: □ American Express □ Discover □ MasterCard □ Visa □ Check here if corporate credit card

□ Check (Payable to MAOFP) Check #______

Name on Credit Card (If different than above) ______

Billing Address (If different than above) ______

City ______State______Zip Code ______

Phone Number: (_____)______

Credit Card Number ______Exp. Date ______CVV Code: ______

Please submit application and payment (if applicable) to the address below.

Michigan Association of Osteopathic Family Physicians

2123 University Park Drive, Suite 100 Okemos, MI 48864

Phone 888-204-9124 Fax 517.708.7250

www.maofp.org