CFPS Membership Dues Form

MEMBERSHIP FORM
Provider Name*

First NameLast NameMD,DO, PA etc
License Number*
For AMA PRA Category 1 Credit™”
Practice Name (if applicable)
Hospital Affiliation (if any)
Preferred Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Preferred Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Email *
example@example.com
Membership
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<< CHECK THIS BOX TO PAY YOUR $100 ANNUAL DUES. (There is a $4.12 PayPal fee.) Scroll down and click on the PayPal link to pay by credit card. Annual Dues
$104.12

Total

$0.00
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The payment is ready! It will be completed once you submit the form.
If you prefer to pay by check, please print and mail this completed form with your check for $100 to:

Central Florida Pediatric Society

514 E Amelia St

Orlando, Fl 32803

(321) 258-9398

http://cfpedsoc.org/membership/
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