2013 Alumni Association Membership Dues

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2013 Alumni Association Membership Dues

To pay your 2013 annual membership dues, please return this form along with your payment to the address below. Make checks payable to: Ochsner Alumni Association. Visit our website www.ochsner.org/alumni and check our upcoming features including the online membership directory and the option to pay your annual dues online.

___________________________________________________________________ First Name Last Name ___________________________________________________________________ Degree (MD, DO, etc.) Specialty ___________________________________________________________________ Address ___________________________________________________________________ City State Zip Code ___________________________________________________________________ Email Address ___________________________________________________________________ Phone Check one box:   

Lifetime Dues $1,000 Lifetime Pledge ($333.33 for current yes, $333.33 charged on 2 other years) Annual Dues for 2013 $50

Credit Card Information: ___________________________________________________________________ Name as it appears on credit card Card Type ___________________________________________________________________ Card Number Expiration Date Security Code Ochsner Alumni Association Brent House Room 240 1514 Jefferson Hwy, New Orleans, LA 70121 TM alumni @ochsner.org • www.ochsner.org/alumni 504-842-7119 CME alumni dues card 2012.indd 1

12/26/12 9:40 AM