South Dakota State Medical Association

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Donation

* Mandatory fields

Contact Information

Prefix

*First name

Middle Name/Initial

*Last name

Suffix

Designation

*Primary Email

This email is where all SDSMA communication will be sent to.

Alternate Email

Primary Phone

123-456-7890

*Privacy Policy

I confirm I have read and accept the terms of the Privacy Policy

Work Information

*Office/Clinic Name

Title

Employment Start Date

April 2024 Select a Different Month (Keyboard shortcut: M)

*Primary Specialty

Secondary Specialty

Home Information

Home/Cell Number

Home Address

Home Address 1

Home City

Home State

Home Zip Code

Personal Information

Date of Birth

Gender

Spouse's Name

if applicable

Maiden Name

if applicable

*Payment frequency

One-time

Monthly

Quarterly

Semi-annually

Annually

*Donation Type

SDSMA PAC

SDSMA Foundation

Student Dues Sponsorship ($100/student)

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.

Comment

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.

Contact Us

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