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.

    After submitting the form, you will be directed to the CAPM payment page, serviced by PayPal. Reenter the total amount of your dues and donation and click on the”Pay with Credit or Debit Card” button. More information will be requested on your method of payment, as with any online purchase.

    (*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.)