First name*:


Last name*:


Email address*:


Degree:


Hospital*:


Office Address:


Hospital Street Address:


City:


State:
(2 Letter Abrv.)

Zip Code:

Phone #*:

*Required information



Submission of 2004 Dues for Established Members

Please submit your $35 check for 2004 dues. If you are a new member and have already submitted a check to Dr. London this calendar year, you do NOT need to submit additional payment. Please send your check (payable to A.V.A.A.) to Pam Kroll at:

Pam Kroll, RN, AA
VA Medical Center, Dept of Anesthesiology (CC-112A)
5000 West National Ave
Milwaukee, WI 53295

Note: As we will be depositing checks in a single batch, you may not see your check clear right away.





© 2001-2005, Association of Veterans Affairs Anesthesiologists

Designed by Solid Sender

Revised -- 11/26/03