Membership Renewal Form

*Cleveland Society of Anesthesiologists*
ANNUAL DUES STATEMENT JANUARY 2004 to JANUARY 2005

ANNUAL DUES $80.00


Please make check payable to CSA and remit to:
Cleveland Society of Anesthesiologists Fairview Hospital, Department of Anesthesiology 18101 Lorain Avenue Cleveland, OH 44111

Tax Deduction Information :
* In fiscal year 2003, 100% of the dues paid by the Cleveland Society of Anesthesiologists are deductible as an ordinary and necessary buisness expense for Federal Income Tax purposes.



CSA Annual Dues; January 2004 - January 2005

Please Complete and return this portion of the statement with your dues payment. ( Retirees and residents are not required to pay dues but must provide member information. )

Name :_____________________________________ Title :_____________________________ Address:_____________________________________________________________________ City :_____________________________________ State :________________ Zip :__________ Phone :_______________________________ Fax :___________________________________ Email :_______________________________________________________________________