Membership Application - 2026 Special 180th Anniversary Pricing


Personal Information
Full Name:
First
Middle
Last
Designation (FACS, MBA, MPH, etc.)
Informal Name/Nickname

Contact Information
Email (preferred)
Email (alternate)
Cell Phone

Address Information
Practice Group Name
Office Address
	City
	State Zip
Specialty

Home Address
	City
	State Zip


What prompted you to join OSMA?


Were you encouraged by a colleague to join OSMA?
Please provide the name of the colleague who referred you so they can be credited for the referral:


2026 OSMA Membership:
Membership Fee:
2026 promo - In celebration of OSMA's 180th anniversary, join for just $180 for 2026!
1st year pro-rated dues
2027 renewal invoicing will begin in the fall for your 2nd-year discount membership, 2026 membership will expire 12/31/2026.

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