Become an ACGIM Member
ACGIM
Membership Application
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Membership Information (please print)
Name and Degree: _________________________________________________
Institution: _______________________________________________________
Title: ____________________________________________________________
Department: ______________________________________________________
Mailing Address: home work |
Alternate Address:home work |
| _____________________________ | _____________________________ |
| _____________________________ | _____________________________ |
| _____________________________ | _____________________________ |
Work Phone: ___________________ |
Date of Birth: ___/___/___ |
Home Phone: __________________ |
Male Female |
FAX: ___________________ Date became Chief or Assoc. Chief: ___/___/___ |
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| Email: ___________________________________________________________ | |
| Medical School Affiliation: ___________________________________________ | |
| Hospital Affiliation:
_________________________________________________ Membership Dues Categories: please check one of the following (Membership year Jan-Dec) Full Member - Full members must be Chiefs of divisions of General Internal Medicine at teaching institutions (as defined by AAMC), or general internists who are chiefs/leaders of health services research oriented sections or other academic sections. Full members shall have the right to vote and hold office. 2008 Dues rate $350 Full Member - Institutional Discounts - A discount is available for multiple memberships from the same institution. After 2 members from the same institution pay at the full rate, every member there after is half the price. 2008 Dues rate $175
Emeritus Member - Emeritus members must be former Chiefs of General Internal Medicine. They shall pay dues at a rate determined by the executive committee and shall have the right to vote, but not run for office. 2008 Dues rate $350
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| NOTE: This payment is only for ACGIM and does not include membership for SGIM. If you have questions regarding membership please call SGIM at (800)822-3060 | |
| 2008 ACGIM Membership Dues | $______ | |
| Total Payment | $______ | |
| Payment Types: | ||
| Check Enclosed | ||
| Visa Mastercard | ||
Card Number: ____________________________________ Exp. Date ______________ |
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Name on Card (print): _______________________________________ |
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Billing Address: ____________________________________________ |
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Signature: ________________________________________________ |
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RETURN
COMPLETED APPLICATION AND PAYMENT TO: |
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