Member Contact Information 2006 Update Form

Member Contact Information 2006 Update Form Please complete this form if your mailing address, phone, fax, or email has changed. This will ensure that you continue to receive uninterrupted member benefits, including: the Journal of the American M edical Directors Association , Caring for the Ages, AMDA Reports Please print or type and mail to: American Medical Directors Association Membership Department 10480 Little Patuxent Parkway, Suite 760 Columbia, MD 21044 OR fax to (410) 740-4572, attention Nicole Germain, Membership Department. OR from www.amda.com, log-in as a member and update your personal profile.

Name _______________________________________________________________Degree(s) _______________________________ Title ________________________________________________________________________________________________________ Mailing Address _____________________________________________________________________________________________ ____________________________________________________________________________________________________________ City/State/Postal Code_________________________________________________________________________________________ Province/Country (if outside U.S.)_______________________________________________________________________________ Office Phone (______) ____________________________________ Fax (______) _________________________________________ E-mail Address ______________________________________________________________________________________________ Medical Specialty __GP __FP __IM __Other ______________________________________________________________________ Area(s) of Interest in Long Term Care ____________________________________________________________________________ ____________________________________________________________________________________________________________ Facility (if more than one, please attach a second page) ____________________________________________________________ Facility Address _____________________________________________________________________________________________ City/State/Postal Code_________________________________________________________________________________________ Province/Country (if outside U.S.)_______________________________________________________________________________ Please check all that apply to you: I serve as a __ Medical Director __ Attending Physician __ Other ____________________________________

Please check here if you do not want AMDA to share your name with other organizations or individuals outside of the association. Questions? Contact Nicole Germain, Membership Coordinator at (410) 992-3114 or ngermain @amda.com