MDPAC Membership Application

All Fields are required for submission.
Personal Inforation:
First Name
Middle Initial
Last Name
Mailing Address
City
State
Zip
Phone
E-mail
Membership Information:
Membership Type
 Physician Spouse Resident
Student Alliance Member Family Membership
Physician Spouse Name
Payment:
Payment
 $300 Club Membership
$225 Family Membership
$150 Sustaining Membership
$20 Resident/Student
Donation Type
 Corporate Credit Card
Personal Credit Card
If you prefer to pay by check, please print out this completed form and mail to:

MDPAC
120 West Saginaw
East Lansing MI 48823

Please make check payable to "MDPAC"
*Type of card
 Visa Mastercard
Discover     American Express
*Complete name on card
*Number on card
*Expiration date
* Indicates that the information is submitted through our secure web server.


If you have questions, please contact Josh Richmond,
at (517) 336-5788, or jrichmond@msms.org.

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