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 862, Ansonia Station New York, New York 10023 SUSMA BRINGS US TOGETHER AND KEEPS US IN TOUCH YOUR MEMBERSHIP FEE AND GIFTS ARE 100% TAX DEDUCTIBLE THANK YOU FOR YOUR PAYMENT