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1112 Harding Place, Suite 100, Charlotte, NC 28204 | 704-376-3688 • FAX 704-376-3173 | meckmed@meckmed.org
2020 MEMBERSHIP RENEWAL
PERSONAL INFORMATION
________________________ ________________________ ________________________ ________ MD ____ DO ____ PA ____
Last Name First Name Middle Suffix
_________________________________________________ _____________________________________ ___________________
Home Address City Zip
_________________________________________________ _________________________________________________________
Primary Phone Preferred Email
PRACTICE INFORMATION
___________________________________________________________________________________________________________
Practice Name
_________________________________________________ _____________________________________ ___________________
Practice Address City Zip
________________________________ ________________________________ _________________________________________
Practice Phone Fax Preferred Email
MD or DO: $300 Select a membership option: PA MCMS Membership Only: $105
Early Retired/Part-time: $150 PA Dual MAPA/MCMS Membership: $90
I would like to make a donation to the Medical Society. $ _______________ TOTAL: $ _______________
Pay online … PAYMENT OPTIONS
Pay by Credit Card (VISA or MasterCard)…
at Meckmed.org
___________________________________ Complete this form and fax to secure fax at 704-376-3173. You will receive a receipt by email.
Account #: ____________ ____________ ____________ ____________ Expiration Date: _____________
Pay by Check …
Signature of Cardholder: ______________________________________________________________________
Make check payable to Mecklenburg County
Medical Society. Include a copy of this Printed Name of Cardholder: ___________________________________________________________________
renewal form with your payment and mail
to MCMS, 1112 Harding Place, Suite 100,
Charlotte, NC 28204.
Optional Contribution to MCMS PAC (Meck PAC) - not tax deductible $ _______________
Make PERSONAL check payable to Meck PAC and mail to MCMS at the above address.
N.C. law requires political committees to report the name, mailing address, job title or profession and name of employer or
employer’s specific field for each individual whose contributions’ aggregate is in excess of $100 in an election cycle.
MCMS dues are deductible as an ordinary and necessary business expense, not as a charitable contribution.
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