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WAMPAC


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Physician, Physician Assistant & Spouse
Membership Categories
(please select one)
Diamond Club $300
Sustaining Member $150
Spouse Member $75
Student Member $20

General Information (please type in)
* = required.
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone Number:
E-Mail Address:

State law requires the following information:
*Self-employed/sole proprietor or student

 OR
*Employed or limited partner with:
*Company Name:
*City:
*State:

Contributions are not tax deductible. ($50 of the Diamond Club, Physician Member and Spouse Member categories goes to AMPAC). WAMPAC and AMPAC are separate segregated funds established by the WSMA and AMA, respectively. Contributions are not limited to the suggested amounts. Neither WSMA nor AMA will favor or disadvantage anyone based on the amounts or failure to make contributions. Contributions are subject to FEC regulations. A portion of non-corporate contributions to AMPAC may be used to make campaign contributions to candidates running for federal office in Washington state.

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