Application
You can print out this page, fill it out, and send it with a check to:
Detroit Guild of the Catholic Medical
Association
Dr. Kathryn Kristoff, 15239 Maxwell, Plymouth, MI 48170
Annual Dues Are:
| ___ | Residents & Fellows................................................................... | $10 |
| ___ | New Physicians (in their first 2 years of practice)......................... | $30 |
| ___ | Physicians in active practice........................................................ | $50 |
| ___ | Retired Physicians...................................................................... | $30 |
| ___ | Affiliated Health Professionals..................................................... | $25 |
| ___ | General Public............................................................................ | $25 |
| ___ | Students, Religious & Clergy...................................................... | Free |
I wish to apply for membership in the Detroit Guild of the Catholic Medical Association.
Please check one of the above categories and fill out the requested information below:
Specialty: _____________________________________________________
Name: ________________________________________________________
Title: M.D. D.O. R.N./B.S.N. PHARMACY
DDS DPM OTHERS(pls. indicate)
Address:___________________________________________________________________
City: ________________________________
State: _____
Zip Code: ________________
Phone: ________________________ Fax: ___________________ E-mail: ________________
Referred by: ______________________________________________________________