Clinic Membership Application Form

ACPOC Clinic Membership Application

To apply for membership please complete all questions and submit payment Membership Dues (10% discount rate): Physician: $285($256.50) Non-Physician: $175($157.50) Corresponding: $120($108)
Name

First NameLast Name
Membership Type*

3+ Members (10% off)4+ Members (10% off)5+ Members (10% off)6+ Members (10% off)7+ Members (10% off)8+ Members (10% off)9+ Members (10% off)10+ Members (10% off)
Clinic or Company *
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Clinic Work Number
Name*

First NameLast Name
E-mail*
example@example.com
Professional Designation*
Job Title*
Membership Type*

Physician MembershipNon-Physician MembershipCorresponding Membership
Name*

First NameLast Name
E-mail*
example@example.com
Professional Designation*
Job Title*
Membership Type*

Physician MembershipNon-Physician MembershipCorresponding Membership
Name*

First NameLast Name
E-mail*
example@example.com
Professional Designation*
Job Title*
Membership Type*

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership
Name

First NameLast Name
E-mail
example@example.com
Professional Designation
Job Title
Membership Type

Physician MembershipNon-Physician MembershipCorresponding Membership

My Products

Physician Membership with 10% discount

$256.50 Quantity

Non-Physician Membership with 10% discount

$157.50 Quantity

Corresponding Membership with 10% discount

$108.00 Quantity

Total

$0.00

Credit Card Details
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Credit Card Number	Security Code
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ACPOC Clinic Membership Application