Marshall University Joan C. Edwards School of Medicine Alumni Association
Membership Application (July 1 - June 30)

Name:____________________________________Class Year_________________

Home Address:_______________________________________________________

___________________________________________________________________

Phone: (Home)__________________________(Work)_______________________

Date of Birth:_________________EMail:__________________________________

Membership:

____Annual Membership     $50.00
      (First year complimentary for PGI's)

____Lifetime Membership    $500

____Associate Membership  $55.00 (non-voting membership)
      (West Virginia Physicians, former residents who are not school of medicine alumni and
         all present and previous faculty are eligible.)

Method of Payment:

_____Check is enclosed made payable to Marshall University Foundation Inc.

_____VISA    MASTERCARD    DISCOVER    AMERICAN EXPRESS  (Circle one)

Name on Card:_________________________________________________________

Card No: ______________________________________________Exp. Date________

Amount Charged:_____________________________________________

Signature:______________________________________________________________