Society of Primary Care Policy Fellows
Membership Form

Type of membership:    Active    Associate    Supporting

Please print or type:

Full name:
Credentials
Title/Position
Org/Business Name:
Preferred Mailing Address:   Business   Home
Address:
Work phone:		Work fax:
Home phone:		E-mail address:
PCPF Class:	(if applicable)

Please identify your areas of interest in research, education, policy, and/or service relative to primary care:		Are you interested in having your name put forward for leadership opportunities as they arise?   Yes   No
1.
		Do you wish to serve on a committee? Policy/Legislation   Practice Education               Research
2.
3.
ACTIVE Membership Candidates eligible for Active member status are veteran fellows of the U.S. Public Health Service Primary Care Policy Fellowship. Active members are eligible to vote and to hold an elected position on the Board of Directors. Annual Dues: $100		SUSTAINING Membership This category of membership is open to individuals, a group of individuals, a corporation, a business organization, an agency, or an institution interested in supporting the Society goals and in achieving its goals by contributing financial support. Annual Dues: $150
ASSOCIATE Membership Candidates for Associate member status are faculty of the fellowship and/or other persons interested in fostering the objectives of the Society. Associate members are not eligible to vote or to hold elective office. Annual Dues: $80

Return application w/dues payment to:

Society of Primary Care Policy Fellows
1522 K Street, NW, Ste. 702
Washington, DC 20005