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Membership Renewal: Form for FAX back or payment by mail
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MSEPS MEMBERSHIP RENEWAL
 Member Profile (see below)e Must be Completed to Activate Membership Renewal or New Application
 
_______________________________________________, MD
Address:__________________________________________________________________________________
City/State/Zip______________________, MD _______   Phone: ______________   FAX: _______________   
 
MSEPS DUES STATEMENT
ACTIVE Membership:             $ 650.00
PAC Contribution:                + 150.00 *
Total:                                      $ 800.00
 
This statement reflects membership dues of $650 and a voluntary contribution of $150
to the MSEPS Political Action Committee. 
Members have the right to refuse to contribute to the PAC without reprisal.
 
 
METHOD OF PAYMENT: 
Please make checks payable to MSEPS and send to
                        MSEPS                                                
                        1211 Cathedral Street/Baltimore, MD 21201
                        410.244.7320 / FAX: 609.392.2664 / www.marylandeyemds.org
            Credit Card          
Circle One: MC, Visa    Total Amount of Charge: $____________ 
Credit Card Number: _________________________________________________________________________
CVV # (back of card) ______________________Expiration Date: _______________________________________
            Cardholder Name: _____________________________________________________________________________
            Cardholder Telephone Number: __________________________________________________________________
            Cardholder Billing Address:______________________________________________________________________
            ____________________________________________________________________________________________
            Cardholder Signature: __________________________________________________________________________
 
Full-Time Membership: $800 includes $150 voluntary contribution to the MSEPS PAC
Part-Time Membership: (practice <20 hrs/wk) $600 includes $150 voluntary contribution to the MSEPS PAC
New Practitioners in Second Year of Practice: $300 includes $150 voluntary contribution to the MSEPS PAC
New Practitioners in Third Year of Practice: $475 includes $150 voluntary contribution to the MSEPS PAC
New Member and in Practice less than 5 years, no charge: a $150 voluntary contribution to the MSEPS PAC is suggested but not required.
Physicians in Training: Complimentary Membership
In most cases medical association dues may be partially deductible as professional or business expenses. Dues and contributions to the MSEPS PAC are not deductible as charitable contributions for federal income tax purposes. Estimated medical dues association non-deductibility percentage is 7%.
 
 
MARYLAND SOCIETY OF EYE PHYSICIANS & SURGEONS

1211 Cathedral Street

Baltimore, MD 21201

410.244.7320 / FAX: 609.392.2664 / www.marylandeyemds.org  
 
 

 

The following must be completed in order to activate memberships.
Be thorough. Members-only will be featured in the new MSEPS website “Find An Eye MD” search engine!
 
MEMBER PROFILE
 
NAME                                    _______________________________________________________________________
Required
 
OFFICE ADDRESS             _______________________________________________________________________
Required                             
 ______________________________________________________________________
 
_______________________________________________________________________
 
OFFICE PHONE                 ___________________________________FAX ________________________________
Required
 
EMAIl*                                   ___ ___________________________________________________________________
(Required to receive member alerts, special invitations, electronic newsletters)
 
SATELLITE OFFICE(S)      _______________________________________________________________________
Required
                                _______________________________________________________________________
                                               
SATELLITE PHONE           __________________________________FAX_________________________________
 
HOME ADDRESS               _______________________________________________________________________
Required                              
_______________________________________________________________________
 
HOME PHONE                     __________________________________FAX _________________________________          
 
WEBSITE                              _______________________________________________________________________
 
COUNTY OR CITY OF RESIDENCE _______________________________________________________________
Required
 
VOTING DISTRICT              _______________________________________________________________________
 
EDUCATION (Name of Schools, Location and Dates of Graduation)
 
College                  _______________________________________________________________________
 
Medical School    _______________________________________________________________________
 
Residency             _______________________________________________________________________
 
OPHTHALMOLOGY SUBSPECIALTY (if applicable)__________________________________________________
(glaucoma, retina, neuro, etc.)
 
 
 
___________________________________                    ___________________________________________________
Date                                                                           Signature

 

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10/25/2017
11th Annual MSEPS Membership and General Business Meeting

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MSEPS / 1211 Cathedral Street / Baltimore, MD 21201 / 410-244-7320