"*" indicates required fields Name* First Last Email* Phone*Address* Home Address City State / Province / Region ZIP / Postal Code Years in PerfusionHospital Affiliation(s)*Do you consent to having your information in the Michigan Perfusion Society Directory? Yes NO Membership Class* Class A: Practicing Perfusionist (Annual Dues $25) Class A Emeritus Voting: Retired from Perfusion (Annual Dues $25) Class A Emeritus Non-Voting: Retired from Perfusion (Annual Dues $0) Class B: Out of State Practicing Perfusionist (Annual Dues $25) Class C: Current Student of Perfusion (Annual Dues $0) This field is hidden when viewing the formClass A: Practicing PerfusionistClass A: Practicing Perfusionist (Annual Dues $25)This field is hidden when viewing the formClass A Emeritus Voting: Retired from PerfusionClass A Emeritus Voting: Retired from PerfusionThis field is hidden when viewing the formClass A Emeritus Non-Voting: Retired from PerfusionClass A Emeritus Non-Voting: Retired from Perfusion (Annual Dues $0)This field is hidden when viewing the formClass B: Out of State Practicing PerfusionistClass B: Out of State Practicing Perfusionist (Annual Dues $25)This field is hidden when viewing the formClass C: Current Student of PerfusionClass C: Current Student of Perfusion (Annual Dues $0)Membership Type* New Renewal (no lapse in membership) Reinstatement (lapse in membership) Agree Terms & Conditions?*These terms and conditions outline the rules and regulations for the use of MI Perfusion Society’s Website, located at Website.com. By accessing this website we assume you accept these terms and conditions. Do not continue to use Website Name if you do not agree to take all of the terms and conditions stated on this page. I agree to the terms & conditionTotal Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Δ
