Membership Form

* indicates required fields.
Name*:
Email*:
Company Name*:
Position / Title*:
Address*:
City*:
State*:
Postal Code*:
Phone*:
Fax:
Applying for what membership*:	Active Affiliate Student
If Active Member Select:
Number of Physicians: *Required only if "Active Member" is selected
If Affiliate Member:
Reason for Applying*:
Year started with present employer*:
Are you a Member of MGMA Alabama?*	Yes No
Are you a Member of MGMA National?*	Yes No
Are you a Member of American College of Medical Practice Executives?*	Yes No
Briefly describe Job duties as they relate to MGMA and this application*:
Who may we thank for referring you for MGMA Birmingham membership?

You will be invoiced for applicable dues once your application is approved.