UPGRADE YOUR MEMBERSHIP!
• • • • • • •
Complete this form and return to:
21400 International Blvd., #207 SeaTac, WA 98198
Name
Address Phone
Payment Information Card Number
Name on Card
Prices do not include tax. Upgrade to
Annual Semi-Annual Quarterly Monthly Opioid Brochures
________ x (pkg. of 25) Clinic
City/State/ZIP Email
Rainier Olympic
Expiration Signature
CVV Code
Billing ZIP
Visa MC Disc AmEx
All premium memberships must be set up for automatic payment. The WSCA does not maintain credit card numbers on file; membership upgrade requires resubmitting payment information. Initial payment for monthly payment plans must be equal to three months’ dues at the selected premium level. Initial dues payment will be prorated by any unused amount of dues already paid. If already registered for conference or annual meeting, initial dues payment will be prorated by the registration amount already paid. Monthly payments will resume at the regular monthly rate three months after initiating premium membership. Additional forms may be required to initiate all benefits of your selected premium membership.
Ple xus
Oct/No v 2019 23
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