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.

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


Preferred Mailing Address:
The address above is: HomeWork

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: $10Medical Student: $5


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.)