Membership Category Active Member ($95.00)Associate Member ($95.00)Resident Member ($0.00) An individual who is a physician or scientist holding an MD, DO or PhD degree. A healthcare professional that does not satisfy the criteria of Active Membership, such as an allied health professions (Nurse, NP, PA). A resident currently in training at an accredited medical program. Resident Program Information Program Name: Graduation Year: Applicant Information --Select Prefix-- Assoc. Prof. Col. Commander Dr. Drs. Hon. Judge LT/COL LTC Maj. Miss Mr. Mrg. Mrs. Ms. Prof. Prof. Dr. Rev. Prefix Professional Title First Name Middle Name Last Name --Select Suffix-- II III IV Jr. Sr. Suffix Designation/Degrees Birth Date (MM/DD/YYYY) Gender Email Contact Phone Applicant Addresses --Preferred Mailing Address-- Office Home Preferred Mailing Address Office Address Include my work information in the member directory of the website. Company Name Office Address Line 1 Office Address Line 2 Office Address Line 3 Office City Office State/Province Office ZIP/Postal Code Office Country Office Phone Website URL Home Address Home Address Line 1 Home Address Line 2 Home Address Line 3 Home City Home State/Province Home ZIP/Postal Code Home Country Home Phone TOTAL AMOUNT DUE: Payment Information (must be made in U.S. dollars) CheckCredit Card --Select Card-- Visa MasterCard American Express Card Type Name As It Appears on Card Credit Card Number Expiration Date (MMYY) Card Verification Number Billing Information Billing Street Address Billing ZIP Code If paying by check, make check payable to: American Society for Men’s Health Mail payment to: American Society for Men’s Health Two Woodfield Lake 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 Signature Email Address Telephone Number Signature Date I Agree that I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to ASMH in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting “I Agree” to be my legal signature to this agreement. Enter Security Code: 976662