Photomedicine Society Dues Solicitation
2010 Annual Dues

$125 (U.S. dollars); Residents/Fellow $80
Registration for Annual Meeting at the door $100

Deadline: December 31, 2009
Name _______________________________________________
Address _____________________________________________
_____________________________________________
City,State,Zip _________________________________________
Country _____________________________________________
Phone _______________________
Fax _________________________
Email ________________________
(Please indicate if change of address or new member)

In order to properly credit your dues, please print your name on the face of
your remittance check or money order payable in U.S. currency by bank
check, money order, or VISA/MASTERCARD/AMERICAN EXPRESS
INDICATE METHOD OF PAYMENT BELOW:
___ Check enclosed payable to Photomedicine Society
___ Mastercard ___VISA ___ American Express
Print card# in space below
__/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/
Expiration Date _______ Signature ___________________________

PLEASE CIRCLE ONE:
$125 Regular Membership; $80 Resident/Fellow

Please submit form with check, money order or credit information to:
Heidi Jacobe, M.D. (Sec/Treas)
c/o Department of Dermatology
UT Southwestern Medical Center
5323 Harry Hines Blvd.
Dallas, TX 75390-9069
Phone: 214-648-8806 Fax: 214-648-7678
Email: photomed@utsouthwestern.edu