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.
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
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