MEMBERSHIP APPLICATION & RENEWAL
FORM 2018-2019
GENESEE COUNTY MEDICAL SOCIETY
ALLIANCE
Alliance Member’s Full Name: _________________________________________________
Mailing Address:_____________________________________________________________
City, State, Zip:______________________________________________________________
Home Phone # __________________________*Cell Phone if desired____________________
*E-Mail Address:______________________________________________________________
Physicians Full Name:_________________________________________________________
Annual Dues:
GCMS Alliance $30.00
MSMS Alliance $32.00 - ($25 if retired)
IMPORTANT:
Check payable to: GCMSA
Total Remittance $______
Mail to: Cheryl Thoms
GCMS Alliance Membership
1213 Carter Dr.
Flint, MI 48532
Phone # 732-7719 if you have any questions