Membership application form To apply for PEIMA membership, please fill in and submit the form below. Please review the different membership types and associated fees before applying. Contact information First name Last name Email Cell phone number Alternate phone Mailing address Membership type Please indicate which type of membership you are applying for. Membership type < select one > Midwife, professionally active ($484.45)Midwife, professionally inactive ($30) Student midwife ($30)Supportive member ($30) I'm a member of I would like to add CAM membership to my PEIMA application ($110) Are you a real person? (no robots please) Please answer the following question: How many legs does a dog have? Your answer