Affiliate Members

Affiliate Membership – $75 annually

As an Affiliate Member you will receive:

Please fill out the form below, and we will be in touch to process payment following membership verification.

Name

First

Last

Designation(s)

Title

Organization

Primary Membership (Chapter)

Member Type

Member Number

Expiration Date

Note: Your MPIRMC Affiliate Membership will be processed upon verification of your current MPI membership status.

Street Address

Address Line 2

City

State

ZIP / Postal Code

Country

Phone

Fax

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