SHIRAZ UNIVERSITY SCHOOL OF MEDICAL SCIENCES ALUMNI ASSOCIATION, USA, INC. FOUNDED 1984 MEMBERSHIP APPLICATION Name: _______________________________________________ Address:_______________________________________________ _______________________________________________________ Office Address: ________________________________________ ________________________________________________________ Phone: Home: ____________ Office: ______________ Fax: _____________ E-mail Address: ________________________________________ Year of Graduation: ______Specialty: ___________________ __MD __DDS __RN __PT __Associate Member My/Our gift of $_______ to SUSMA Fund is enclosed. Please direct this gift to: __Scholarship Fund __Library __Educational Program __Health Assistance Please keep us informed of news about yourself and/or alumni friends: _____________________________________________________ _____________________________________________________ _____________________________________________________ Please print and forward with your check payable to SUSMA in the amount of $50.00 for membership dues to: Shiraz University School of Medical Sciences Alumni Association, USA, Inc. P.O. Box 630311 Little Neck Station Little Neck, New York  11363-9998 SUSMA BRINGS US TOGETHER AND KEEPS US IN TOUCH YOUR MEMBERSHIP FEE AND GIFTS ARE 100% TAX DEDUCTIBLE THANK YOU FOR YOUR PAYMENT