Please complete all sections of this form. Information is for statistical purposes only and is considered confidential. When applying for multiple memberships, please use a separate "Application for Membership" for each member.
Name:
Title:
Business:
Address:
City: State: Zip:
Phone: Fax:
e-mail:
Please check the type of membership for which you are applying:
New Member Renewal
INDIVIDUAL Annual Fee: $115.00
MULTIPLE** Two or more people applying from the same office receive a 10% discount on each membership. Annual Fee: $105.00 each.
CORPORATE** Corporation or Business name appears on all Association documents rather than an individual's name. All employees may take full advantage of the savings and benefits of Corporate Memberships. Annual Fee: $295.00 for 1-4 employees
Medium Corporate** - 5-10 Employees $85 per employee.
Large Corporate** - Over 10 Employees - $75 per employee.
**A list of each employee's name, address and phone number must be provided with application.
You may print this form out from your browser and mail it with your payment, or transmit your form electronically, followed by payment. Thank You.
Check Money Order
Please mail payments to Medical Association of Billers 2620 Regatta Dr., Suite 102 Las Vegas, NV 89128
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Card Number: Exp Date:
Exact Address on Billing Statement:
Security code from back of card: 3-4 digits
Years in billing: Years in this field:
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Thank you for your Application. The Medical Association of Billers (MAB) is your Trade Association.
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