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18th Sep 2010

TIPS Presents

**Shanti: Avatars of Peace

Second Annual TIPS Charitable Gala

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Invoice/Renewal Form - Physicians

1. Physician Application Information

Title
First Name
Last Name
Spouse's Name (if also physician)
Business/Group
Speciality
Street Address
City
State	None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
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Home Phone
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Email
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Membership	1 year membership $ 40 4 year membership $ 140 Life membership $ 500 Resident/Fellow 1 year $ 25 Medical Student 1 year $ 15

           

2. Payment Information

    $ 40     1 year membership
    $ 140   4 year membership
    $ 500   Life membership
    $ 25     Resident/Fellow 1 year
    $ 15     Medical Student 1 year

           

Please Make checks payable to:
Anupama Gotimukula
7447 Hovingham
San Antonio, Tx 78257

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