* Enclosed is $65.00 for the 2009 membership year. This entitles me to receipt of the ACPM Headlines and the American Journal of Preventive Medicine, and the APMR list
serve.
This box must be checked for the transaction to be completed.
Membership year 1/1/09-12/31/09
*
Denotes Required Field
*Name:
*Address:
*City:
*State:
*Zip:
Phone:
Fax:
Social security number:
optional
*E-mail address:
*Residency Program
(Location):
What type of residency program are you attending? (Ex: Aerospace, GPM, Occupational, Internal Medicine, etc).
* Training Year:
CLINICAL
ACADEMIC
PRACTICUM
ACADEMIC/PRACTICUM
* Month & Year Residency Will Be Completed:
*
PAYMENT
* CREDIT CARD NUMBER
* EXPIRATION DATE
American College of Preventive Medicine
1307 New York Avenue, N.W., Suite 200, Washington, DC 20005
Tel: (202) 466-2044 | Fax: (202) 466-2662
Email: info@acpm.org
