LOS Dues Form

LOS Dues Form

January 1, 2026-December 31, 2026
About You
Membership Type*
Full Name*

First NameMiddle NameLast NameSuffix
Your Credentials (Choose all that apply)*

MDDOFACSFASMBSRNLPNCRNPAPRNMSNRDLDPAPhDOther
Your Profession*
Other
Practice/Program Name/Company Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Admin
Do you have an administrator we should copy on all your emails?
Name

First NameLast Name
Their Title
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Join a Committee

Get Involved with LOS!
Check which committee you are interested in joining.

AdvocacyAPPAdvanced Practitioner (PA, NP)Behavioral HealthBylawsCommunicationsMembership CommitteeNutritionPedsEducationFinance
Dues Payment
2026 Trainee Membership Level

Resident - freeMedical Student - freeOther
How will you be paying?*

checkcredit card
2026 Membership Level

2026 Physician/Surgeon Membership - $1502026 Non-Physician Membership - $752026 Industry/Non-Profit Membership - $350
Please make checks payable to:
Louisiana Obesity Society

Print this form and mail with your check to the address below:

LOS
c/o Janna Pecquet
2213 Danny PK
Metairie, LA 70001

Questions? email louisianaobesitysociety@gmail.com
Dues Receipt

We will be happy to send you an email receipt for your dues. We will email your receipt to the one provided or the person of your choice. Just provide their email address after selecting other below.

Should be Empty:

Rows	Send email	Email Address
Myself
Your Admin
Other

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

LOS Dues Form

About You

Your Admin

Join a Committee

Dues Payment

Dues Receipt