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FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPhone *Number where you can be reached regarding TMDA membership.Fax *Fax where you can be reached regarding TMDA membership.Email Address *E-mail where you can be reached regarding membership (this address will not be shared without your permission.LTC Facilities *Please list the LTC facilities at which you work. Please include: street address, city, state and zip code. Put each facility on a separate line.New Members *New Member Physician: TMDA ONLY: $37.50 (regularly $75.00)New Member Physician: TMDA/TGS: $67.50 (regularly $135.00)New Member Health Care Professional: TMDA ONLY: $18.75 (regularly $37.50)New Member Health Care Professional: TMDA/TGS: $33.75 (regularly $67.50)Please select your desired membership(s)Check the appropriate membership box *Long Term Care PhysicianOther PhysicianLicensed Health Care ProfessionalRetiredAffiliateStudentI am interested in working on the following committee(s) *Quality Assurance/Patient CareEducation/ProgramFinancePublic PolicyMembershipSend Payment After you submit this membership dues form, you will be taken to a payment page where you can choose to pay your membership dues with a credit card using PayPal's secure onine system, or you may elect to send in your payment via fax or U.S. mail. Please be sure to click the submit button below.Payment Method *Select your fee options on the next page and than click the 'Paypal' button to submit payment.Mail payment to TMDA Maggie Hayden, Executive Director, TMDA, P. O. Box 130963 - Dallas, TX 75313-0963Submit