Namcp Individual Membership Application

You may mail this application along with a check to the above address.  If you experience any difficulty, please feel free to print and fax your registration to us at (804) 747-5316, or call us and give us your information over the phone by calling (804) 527-1905.

   

 We encourage you to complete your online registration at this time.  Our site is protected by VeriSign, the industry leader in encryption.
Name:
Degree:
Date:
Title:
Company:
Street:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Specialty:
Member Code:
Referred By:

Please Check One That Best Describes Where You Work:  

 		   If other, please specify:

Department /Primary Area of Responsibility:
  		  If other, please specify:

Mode of Practice:
 		    

Types of Managed Care Organization(s) With Which You Are Affiliated Or Have Contracts As A Provider:

 		    
   
Payment  
New Physician $195 Renewal Physician $195
New Nurse/PA $50 Renewal Nurse/PA $50
New Resident/Student $25 Renewal Resident/Student $25
New Other Professional - Associate $300 Renewal Other Professional - Associate $300

(NAMCP Tax ID# 54-1566359)
If you wish to phone in your credit card number, leave the card number entry blank and phone in your number to : (804)-527-1905.

Card Type: MasterCard   Visa     American Express
Credit Card #:
Exp. Date:
CardHolder Name
3 digit CVV2 code on back of card:
Comments:


Signature (mail-in only)__________________________________________

Check #: _______________________________

 

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For Additional Information

Phone: (804)-527-1905
Fax: (804)-747-5316
email: info@namcp.org

NAMCP
4435 Waterfront Drive, Suite 101, P.O.Box 4765
Glen Allen, Virginia 23058-4765

Federal I.D.# 54-1566359

A nonprofit 501(c)6 association
Membership dues are not deductible for federal income tax purposes but may be deductible as a business expense. Consult your tax advisor for more information.
Copyright © 2007 NAMCP. All rights reserved.
Revised: January 23, 2008.