FEDERATION OF PHYSICIANS AND DENTISTSApplication for Private Practice MembershipNAME____________________________________________________________________ ADDRESS________________________________________________________________ CITY____________________________________STATE________ZIP_________________ OFFICE PHONE___________________________OFFICE FAX______________________ OFFICE MANAGER_________________________EMAIL___________________________ HOME ADDRESS___________________________________________________________ CITY_____________________________________STATE________ZIP_________________ HOME PHONE______________________________________________________________ FEDERATION OF PHYSICIAN AND DENTISTS DUES ARE $712.00 ANNUALLY WITHOUT A POLITICAL ACTION CONTRIBUTION OR $738.00 WITH A POLITICAL ACTION CONTRIBUTION. DUES MAY BE PAID IN THE FOLLOWING WAYS. PLEASE INDICATE YOUR CHOICE: CHECK MADE PAYABLE TO THE FEDERATION OF PHYSICIANS AND DENTISTS: _________$712.00 _________$738.00 CREDIT CARD PAYMENT _________$712.00 _________$738.00 OR A MONTHLY CREDIT CARD PAYMENT OPTION IS AVAILABLE _______$59.33 WITHOUT POLITICAL ACTION CONTRIBUTION __________$61.50 WITH POLITICAL ACTION CONTRIBUTION CREDIT CARD INFORMATION FPD ACCEPTS VISA, MASTERCARD AND AMERICAN EXPRESS CARD TYPE_______________________ CARD NUMBER__________________________________________________________________ EXPIRATION DATE__________4-DIGIT SECURITY CODE FOR AMERICAN EXPRESS CARDS____________ MAIL APPLICATION TO: FEDERATION OF PHYSICIANS AND DENTISTS 1310 CROSS CREEK CIRCLE, SUITE C-2 TALLAHASSEE, FLORIDA 32301 OR FAX TO: 850-924-6722
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