Membership Application Form
NCS-ACOFP
Name
*
First Name
Last Name
Email
*
Member information regarding conferences, the monthly newsletter, etc. is shared via e-mail. By providing your e-mail address, you are providing permission for the NCS-ACOFP director to share information with you. Note: e-mail addresses of members are not shared outside of NCS-ACOFP.
Preferred Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you are a physician, please enter the address of your practice or residency site.
Name of Practice
Street Address
City
State / Province
Postal / Zip Code
Select one of the following.
*
My application is for a new membership.
I am applying for renewal of my membership.
Members must be free of felony conviction or any crime relating to or arising out of the practice of medicine. Have you ever been convicted of a felony or crime related to the practice of medicine?
No
Yes (If yes and you wish for your application to be considered by the Board of Directors, send info to director@nc-acofp.org to be shared with Board.)
If you are applying as a student, enter your class status, that is OMS I, II, etc. :
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.
Membership Fees
*
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Resident
$
50.00
Physician
$
150.00
Active Duty Military Physician
$
75.00
Retired Physician
$
25.00
Student
$
Free
Associate Membership (non-physician)
$
125.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: