Renewal Form for Current Members

Fill out the form below for online submission and payment; or click here for a printable copy to complete manually and submit by mail with check to the address on the form.

    Date (MM/DD/YYYY):

    Name (required):

    Post-graduate degrees (e.g., MD, DO, MPH):

    Board Cert(s):

    Preferred Email (required):

    Alt. Email:


    Work Phone:

    Home Phone:

    Cell Phone:
    Preferred Phone Contact: WorkHomeCell


    Work Address:
    Street Address or Box Number:
    City:
    State:
    Zip Code:


    Home Address:
    Street Address or Box Number:
    City:
    State:
    Zip Code:
    Preferred Mailing Address: WorkHome


    Check if a member of: CMA (Calif. Med. Assoc.)ACPM (Amer. Coll. Prev. Med.)


    Employer or main professional affiliation(s) (if retired or medical resident, please indicate):

    Updated personal/prof. info.:

    I would like to become more involved in CAPM (we'll contact you): YesNo


    Membership Category and Dues (required): Regular Membership: $40Retired: $20Resident: waivedMedical Student: waived


    Optional contribution ($15 or more suggested, to replenish Treasury):

    After clicking on "Submit and Pay" below, you will be directed to a payment window, where a credit card or PayPal account may be used. Please list the combined amount of your dues and donation in the "Donation" box.


    For your records, a copy of your submission will be sent to the email address you entered into the "Preferred Email" field above.

    (*Dues and additional contribution may be deductible as a business expense, though not as a charitable donation. CAPM is a nonprofit 501(c)6 corporation, Federal Employer Identification No. 95-6123914.)