2025 OSUMC Professional Staff Fund

2025 OSUMC Professional Staff Fund Dues & Internal Medicine Dues
This form is for individual payments by credit card. Companies wishing to use this payment method will need to complete a separate form for each person.
What type of dues are you paying?*

Professional StaffInternal Medicine
Is this submission from an individual or a company?*

IndividualCompany
Company*
Company Email
(optional, if payer would like a copy of this submission)
Name*

(person payment is for)
Credentials*

DOMDDDSDPMPhDCRNAOther
Mailing Address*

Street Address 2
Phone Number
Email*

Payment Information*

2025 OSUMC Professional Staff Dues

$125.00

2025 OSUMC Internal Medicine Dues

$400.00

Total

$0.00

2025 OSUMC Professional Staff Fund Dues & Internal Medicine Dues