2023 SCOA Membership Renewal

Please note: You will need to allow pop-ups and/or redirects when using this form.

Member Name*

First NameLast Name

Practice Name*

Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

NPI#*

Practice Phone Number*

Area CodePhone Number

Mobile Phone Number (This is an optional field. By providing your mobile number you are opting into receiving text messages from SCOA. This information will not be shared or made public. You may opt out at any time.)

Area CodePhone Number

Members E-mail*

Alternate E-mail

example@example.com

Membership Type

Active Member ($500 annual dues)Associate Member ($250 annual dues)Allied Health Professional ($100 annual dues)

Comments

SCOA Automatic Renewal Program

SCOA will automatically renew your SCOA membership each year on January 5th for $500 using the credit card provided.

The member will be notified, via email, approximately one month in advance of the membership expiration date. If you wish to update your card or opt out of the Automatic Dues Renewal program, you may do so at any time before the automatic renewal date.

Do you agree to participate in SCOA's Automatic Dues Membership Renewal Program?*

Yes, I agree to participate in SCOA's Automatic Dues Membership Renewal Program.No, I don't agree to participate in SCOA's Automatic Dues Membership Renewal Program.

Please note your renewal is not complete until you submit payment. Use this submission form for credit card payments only.

Click the button below and you will be directed to a payment page to enter your credit card information.

Please note: You will need to allow pop-ups and/or redirects when using this form.

SCOA Federal Tax # 57-0743252. Fiscal Year January 1 - December 31.
Please Note: Dues are not deductible as a charitable expense but they may be deductible as a business expense according to the IRS. 86% of your dues were used for direct lobbying expenses and may not be deducted. 100% of any PAC donations are not deductible.