WDMS Committee Registration

You may complete this form online or it may also be downloaded and faxed to 508-754-6246,
or mailed to: WDMS, 321 Main Street, Worcester, MA 01608

*Required

I am willing to serve/continue to serve on one (or more) of
the following committees. Please complete this form even if you are currently serving on a committee.

Public Health Bylaws
Legislative Public Relations
Medical Education Scholarship
Publications Women's Caucus
Membership Awards
Memorials  
*Name:
Professional Title:
Specialty:
Hospital Affiliation:
Preferred Address:
Home Number:
Work Number:
Fax Number:
*Email:
 

 

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Worcester District Medical Society
Mechanics Hall, 321 Main Street
Worcester, MA 01608

Tel 508-753-1579  •  Fax 508-754-6246
Questions? Email info@wdms.org
 All Contents © 2002 Worcester District Medical Society