Membership Registration

Membership Year is JULY 1 – JUNE 30
Dues for this year are $50.00

To pay by check, print an application form and mail to:

Laurie Pechnovnik
Mercy Hospital – Unity Campus
550 Osborne Road NE, MR 52400
Fridley, MN 55432-2718

Complete the form below to pay online with PayPal

Applying for*
- Initial Membership
- Renewal of Membership
- Transfer of Membership
Please note a 4% processing fee will be added to all online payments to help offset PayPal fees incurred.
Name*
First Last
Credentials*
Use existing member information?
- If after reviewing the MAMSS roster on the website, there are no changes to your contact information, please check here
Employer/Organization*
Type of health care entity employed in
Type
Position/Title*
Work Phone*
Extension (if applicable)
Work Fax
Home or Cell Phone*
MAMSS will only call this number if we are otherwise unable to reach you.
Member Primary Email*
Alternate Email*

This email address will only be used to contact you if primary email returns undeliverable.
Preferred Address*
Please enter your preferred mailing address. If you work remotely, we recommend entering your home address to ensure you receive communication from the appropriate regional representative.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthday (optional)
MM slash DD slash YYYY
Are you a member of NAMSS?*
The Minnesota Association Medical Staff Services (MAMSS) recruits and processes its own membership and dues independently from the National Association Medical Staff Services (NAMSS). While NAMSS membership is not a condition of MAMSS membership, it has its own benefits.
- Yes
- No
Digital Signature*
By signing below, I hereby acknowledge that I have reviewed and agree to abide by the MAMSS Bylaws and Policy and Procedures.
Referred by (if applicable):
If you referred by a member of MAMSS, please enter their name here.
Name on Credit Card*
Please enter the name on Credit Card that will be used for Registration. You will make your payment on the next screen.
First Last
Comments
Total
$0.00

Referral Program:

Refer a friend, co-worker or supervisor and receive a $10 Gift Card to Target, Amazon or BestBuy for EACH new member Referral.

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