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Fellowship and Section Dues Payment Form
Fellow Information
*First Name Middle Initial *Last Name Suffix
*Email Address
Detail about your Dues
*Fellowship Dues:
New Fellows Initiation Fees:
  *Note: Fellowship dues are tax-deductible, irrespective of your employment or retirement status.
If you are ONLY paying SECTION DUES, you MUST ENTER $0 in the "Fellowship Dues" field.
  Section Memberships
Section on Medical History
Section on Medicine & The Arts
Section on Public Health and Preventive Medicine
Section on Medicine, Ethics & the Law
Additional tax-deductible contribution to The College
of Physicians’ Annual Giving Program
My employer will match my contribution
Total amount will appear on the next page.
Please complete the following information for the person completing this form (if different than above)
Same as Above
Email Address