MEMBERSHIP RENEWAL FORM

Click here to pay your dues online using a Visa or Mastercard

To pay with a check, complete the information below then print this form and submit with payment to:
DOCARE, 142 E. Ontario, 4th Fl. Chicago, IL 60611

Name:

Degree(s):

Address 1:

Address 2:

City: State: Zip:

Phone: Fax

Email Address:

Would you like to participate
in future DOCARE Missions?

Yes

Maybe

Please select your membership category from the choices below:

Regular	$50 per year
Student (MMYYYY) Date of graduation	$30 for duration of medical school
Intern/Resident (MMYYYY) Date of graduation	$50 for duration of residency
Family includes non-medical spouse and dependent children	$60 per year
Life (must be 60 or over)	$500 one-time payment

PAYMENT INFORMATION:

Visa

Mastercard

Name on Card:

Expiration Date:

Check No.

Once you have completed this form, PRINT and submit with payment to:
DOCARE, 142 E. Ontario, 4th Fl. Chicago, IL 60611