Kentuckiana Rheumatology Alliance

Membership Application

Membership Category

Active Member ($50.00)
Affiliate Member ($25.00)
Candidate Member ($0.00)

Applicant Information

Prefix
Professional Title
Designation/Degrees
First Name
Middle Name
Last Name
Suffix
Birth Date (MM/DD/YYYY)
Gender
Email
Contact Phone

Postgraduate Training Information

Residency
Residency Institution
Residency Location
Residency Graduation Year
Fellowship
Fellowship Institution
Fellowship Location
Fellowship Graduation Year

Applicant Addresses

Preferred Mailing Address

Office Address

Include my office information in the member directory
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

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: Kentuckiana Rheumatology Alliance

Mail payment to:
Kentuckiana Rheumatology Alliance
Two Woodfield Lake
1100 E. Woodfield Road, Suite 350
Schaumburg, IL 60173

Enter Security Code: 455605