Apply Online/Update Profile

Click here to download and print our registration form.

• For downloaded Membership forms, please fill out and send the form to:
  Dr. Jennifer Aquino
  1808 Minor Ave, unit 3002
  Seattle, WA 98101
  Email: Drjenaq1978@gmail.com

"*" indicates required fields

Mark appropriate circle below*

Initial Membership Application

Membership Profile Update

NAME*

(for married females, please include your hyphenated surname)

First Last

BIRTHDATE (Month/Day only)

UPCM CLASS*

MU BATCH*

UPMASA CHAPTER*

SPECIALTY*

STATUS*

(Mark appropriate circle below)

Active medical practice

Retired

In-training

Other

Other profession (please indicate):*

EMAIL ADDRESS*

MOBILE PHONE NUMBER:

MAILING ADDRESS*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

MSPF ANNUAL MEMBERSHIP FEE*

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Regular Member - $100 (please see payment options below)

In-training (Free - confirmation letter from Hospital/Program director must accompany the application form)

Lifetime Member (those who have paid lifetime dues before 2020)

PAYMENT OPTIONS*

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Credit Card: Call Dr. Godofredo Garcia at (740) 803-2966 with your credit card information

Zelle: Scan QR code or send to mspf1933up@gmail.com for the General Fund. Put your full name, email address and “Membership Fee” on the memo.

Check: Please write a check to Mu Sigma Phi Foundation and mail to:
Dr. Godofredo Garcia
3008 Jameson Dr. NW, Concord, NC 28027

Signature*

Date*

MM slash DD slash YYYY