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La Leche League International
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LLLI Medical Associates
Membership Information Form

Membership Information

Membership in the Medical Associates Program is $150 for one year. Please print out and mail this form with your payment to:

La Leche League International Medical Associates Program
957 N. Plum Grove Road
Schaumburg, IL 60173  USA

___ Enclosed is my $150 check or money order payable to LLLI Medical Associates Program.

___ Charge my payment: __MasterCard __Visa __American Express __Discover

Account Number _________________________________________

Exp. Date ____________________  3 or 4 digit Security Code _____________

Signature: __________________________________________

Name (Please print ) __________________________________________

Professional credentials __________________________________________

Field of practice __________________________________________

Email Address __________________________________________

Web site __________________________________________

Telephone __________________________________________

Send Medical Associates Materials to: ____ Home office ___ Business office

Name of Business if applicable __________________________________________

Address __________________________________________

City __________________________________________

State/Province/Country __________________________________________

Zip/Postal Code __________________________________________

 

___ I would like my name listed on the LLLI Web site in the Leader-only section. The contact information above will be listed unless you specify any changes below.

 

___ I would like to answer questions for the Medical Associate column in Leaven

  

(Web page registration)

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