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Contact Information

*First name
Middle Name/Initial
*Last name
*Primary Email
This email is where all SDSMA communication will be sent to.
Alternate Email
Primary Phone

Work Information

Employment Start Date

Home Information

Home/Cell Number
Home Address
Home Address 1
Home City
Home Zip Code

Personal Information

Date of Birth
Spouse's Name
if applicable
Maiden Name
if applicable
 Payment frequency
*Donation Type
Select your donation.

PAC Membership Levels:
•Chairman's Club $1,000
•Senate Club $500
•House Club $350
•PAC Member $200
•PAC Resident $50
•PAC Student $25
*Amount ($USD)
• PAC contributions & Foundation donations are counted in the year received.
If you selected multiple donation types, please specify where funds should be allocated.

If SDSMA Foundation is selected, please specify a specific scholarship fund if desired.

South Dakota State Medical Association
2600 W 49th St Ste 100
Sioux Falls, SD 57105
Phone: 605.336.1965 | Fax: 605.274.3274

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