UMMC Alliance

Membership


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  • UMMC Alliance Membership Registration Form

    Thank you for your interest in the UMMC Alliance! There are two payment options for joining the Alliance or renewing your membership. Select the "Cash or Check" option, complete and print the registration form and mail it along with the total payment to the address provided. If you prefer to pay by credit card, select the "Credit Card" option, fill in the credit card information, and hit the Submit button to process your request.

    Cash or Check
    Print this completed form, attach check payable to UMMC Alliance and mail to:
    UMMC - Room WC-106 (University Hospital)
    Attn. Jonathan Albert
    2500 North State St.
    Jackson, MS 39216

    For further information, contact: 601-984-1324.

    * = Required Fields

    First Name*
    Last Name*
    Email Address*
    Phone Number*()--
    Street Address*
    City*
    State*
    Zip*-
    Annual Membership*
    If couple membership is selected please provide the spouses name:
    I would like to make an additional contribution to the UMMC Alliance in the amount of:
    Total Payment Amount
    Card Holder Name*
    Card Type*
    Credit Card Number*
    Credit Card Expiration Date*
    Credit Card CVV Number*
    Located on the back of the card
       CVV