Printed from: https://www.adfm.org/MembersArea/RenewMembership/Renew-Print

2018 Membership Renewals

INVOICE
 TYPE A

Billing for dues for the Association of Departments of Family Medicine for calendar year 2018:

           Regular member(Chair) ONLY - $1,394.00

 TYPE B

Billing for dues for the Association of Departments of Family Medicine for calendar year 2018:

           Regular member(Chair) and Associate member (Administrator) - $1,703.00

Institution:
Address Line 1:
Address Line 2:
City/State/Postal Code: ,
Country:
Email:
Phone:
Fax:

Current Chair:

First Name:
Last Name:
Suffix:
Credentials:
       Permanent Chair             Interim Chair

Current Administrator:

First Name:
Last Name:
Suffix:
Credentials:


TOTAL DUES PAYMENT: _________________

Make checks payable to: ADFM
REMIT TO: Association of Departments of Family Medicine, 11400 Tomahawk Creek Parkway, Suite 240, Leawood, KS 66211 
 OR email completed form with payment to Priscilla Noland, pnoland@adfm.org or fax 913 906-6096

      VISA       MasterCard       American Express

Credit Card No. ______________________________  Exp. Date  _________

Cardholder _______________________________ Signature___________________________


Dues must be received by Annual Winter meeting to vote.  Dues must be received by July 1 to remain on listserve.

    Copyright 2018 by Association of Departments of Family Medicine