Home About Us Meetings Annual Meeting Meeting Information Registration Hotel Information Travel & Transportation Evening Functions Accreditation Needs & Objectives Program Schedule Past Meetings Join WRA Members Only Advocacy Privacy Policy Contact Us Membership Application Membership Category Lifetime Member ($75.00) Qualified applicants must meet the following requirement: An individual member must be a rheumatology provider residing or practicing in Wisconsin (DO, MD, NP, PA, RN). 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 Designation/Degrees First Name Middle Name Last Name --Select Suffix-- II III IV Jr. Sr. Suffix Birth Date (MM/DD/YYYY) Gender Email Contact Phone Website URL Board Certification Board Certification Year 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 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: Wisconsin Rheumatology Association Mail payment to: Wisconsin Rheumatology Association 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 WRA 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: 715316