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Title

First Name

Last Name

Preferred Email

Preferred Phone Number

Local Extension

Position

Department

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$200/year for Physicians

Total: $

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I agree to become a member of the SMH Medical Staff Association and abide by its bylawas and MSA staff rules

I consent to be contacted occasionally via email to be informed about events, opportunities and services provided by the SMH Medical Staff Association

I consent to using my photographs/videos taken at MSA and FE sponsored events on the website

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Member Information

Membership Type

Total: $

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