Membership Agreement Who is your Physician?*Bart Price, MDPetra Travnicek, MD, FACPYour Name*DOB* MM slash DD slash YYYY Spouse (If Joining)DOB MM slash DD slash YYYY Children 1 (If Joining)DOB MM slash DD slash YYYY Children 2 (If Joining)DOB MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneEmail* Spouse Work PhoneSpouse Cell PhoneSpouse Email Concierge Membership per member Price: $4,000.00 Quantity: Total $0.00 Payment Frequency Annually Semi-Annually QuarterlyPayment Method Electronic Debit from Checking or Savings (upload a voided check to our office) Mailing Check Mastercard/Visa American Express DiscoverUpload a copy of a VOIDED check Drop files here or Select filesAccepted file types: jpg, png, pdf, gif, Max. file size: 128 MB.Credit Card PaymentName on CardCard #Exp DateCVV CodeIs the Billing Address of your Card the same as your home address?*YesNoBilling address of credit card Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your SignatureDate MM slash DD slash YYYY Spouse Signature (If Joining)Date MM slash DD slash YYYY
