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LEASE PRINT OR TYPE Last Name First Name MI If after reviewing the WAMSS website roster there are no changes to your contact information, please check here Phone # Ext. Fax # Employer Email Address Job Title Mailing Address City State Zip I REQUEST MEMBERSHIP IN THE FOLLOWING CATEGORY Active Membership: Active members are those individuals having responsibility in medical staff or related activities (e.g. credentialing, quality, provider relations). Active members shall pay dues a.

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