CHAPTER MEMBERSHIP APPLICATION

____Yes! I'd like to join the Louisianan Chapter.
(Please note: To join the Louisiana Chapter you must be a member of the ACC.)

PRINT THIS FORM, THEN COMPLETE AND MAIL OR FAX.


ACC Membership # (if known)______________________________

Name:_________________________________________________

Address:_______________________________________________

City/State/Zip:___________________________________________

Phone: ___________________________

Fax: _____________________________

Email: _________________________________________________

Dues amount for the Louisiana Chapter is $95 per year!

Method of Payment: (Please circle)
Visa, Mastercard, American Express, Check (enclosed)

Credit Card Number_______________________________________

Expiration Date____________________

Amount $_________________________

Signature _______________________________________________

Mail to:
American College of Cardiology
Attention: Resource Center
9111 Old Georgetown Road
Bethesda, MD 20814-1699

or fax to: 301-897-9745

Questions? Contact Janna Pecquet, LAACC Administrator at 504-841-0371.