SHIRAZ UNIVERSITY SCHOOL OF MEDICAL SCIENCES ALUMNI ASSOCIATION, USA, INC.

 
SHIRAZ UNIVERSITY SCHOOL OF MEDICAL SCIENCES ALUMNI ASSOCIATION, USA, INC. (SUSMA)

SHIRAZ UNIVERSITY SCHOOL OF MEDICAL SCIENCES
ALUMNI ASSOCIATION, USA, INC.
FOUNDED 1984

MEMBERSHIP APPLICATION


Name: _______________________________________________

Address:_______________________________________________

_______________________________________________________

Office Address: ________________________________________

________________________________________________________
Phone: Home: ____________ Office: ______________
Fax: _____________
E-mail Address: ________________________________________

Year of Graduation: ______Specialty: ___________________

__MD __DDS __RN __PT __Associate Member


My/Our gift of $_______ to SUSMA Fund is enclosed. Please direct this gift to:
__Scholarship Fund __Library __Educational Program __Health Assistance

Please keep us informed of news about yourself and/or alumni friends: _____________________________________________________
_____________________________________________________
_____________________________________________________

Please print and forward with your check payable to SUSMA
in the amount of $50.00 for membership dues to:
Shiraz University School of Medical Sciences Alumni Association, USA, Inc.
P.O. Box 630311
Little Neck Station
Little Neck, New York  11363-9998


SUSMA BRINGS US TOGETHER AND KEEPS US IN TOUCH
YOUR MEMBERSHIP FEE AND GIFTS ARE 100% TAX DEDUCTIBLE
THANK YOU FOR YOUR PAYMENT