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Daily, 10am to 5pm
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Mon-Fri, 9am to 5pm
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Fellowship and Section Dues Payment Form
Fellow Information
Title/Prefix
*First Name
Middle Initial
*Last Name
Suffix
Organization
Position/Title
*
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
($40)
Section on Medicine & The Arts
($40)
Section on Public Health and Preventive Medicine
($40)
Section on Medicine, Ethics & the Law
($40)
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
Contact
Email Address
Telephone
By clicking "Continue," you will be redirected to our secure payment server.
