Preliminary Program registration - Renal Physicians Association

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RPA membership applicationSPECIAL ANNUAL MEETING MEMBERSHIP RATE!• <strong>Physicians</strong>$275$100 Savings!• Practice Manager• Advanced Practice Nurse• Physician Assistant$225$50 Savings!❑ Yes, I will Join RPA!Name Gender ❑ Male ❑ Female Date of BirthFirst Middle Last (MM/DD/YR)E-mail Phone fax (office)Mailing AddressCity State Zip❑ By checking this box, I am requesting that information NOT be mailed or faxed to me.Membership dues must be submitted with the membership application. RPA will process payment after the application is approved.Payment ❑ Check Enclosed (make payable to RPA) ❑ Visa ❑ Master Card ❑ AMEX ❑ DiscoverNumber:exp. DateName on Card (Print)SignaturedateNEPHROLOGIST/FELLOW – EducationMedical Schoolyear of GraduationFellowshipAcademic InstitutionCity state Zip year AttendedmARCH 17-20, 2011 Marriott Wardman Park Hotel, Washington, DC14CertificationSpecialty Board Certification (ABIM) ❑ Yes – Year ❑ NoNephrology Board Certification ❑ Yes – Year ❑ NoLicensure InformationLicense #PRACTICE MANAGER/ADVANCED PRACTICE NURSE/PHYSICIAN ASSISTANT ONLYProfessional Reference (must be an RPA physician member)NameMailing AddressTelephone:Send your completed form:By Fax: 301-468-3511By Mail: 1700 Rockville Pike, Suite 220Rockville, MD 20852stateFirst Middle LastCity State ZipI hereby declare that the information provided in this application is complete and true to the best of my knowledge.Signature:For RPA Use Only; Code AMDate ReceivedOffice Signature❑ Approveddate:❑ Denieddate
Don’t miss your chance to be part of the political process!Contribute to RPA PAC today!Political Action CommitteeThe RPA PAC Receptionis for contributors only.❑ YES! I would like to make my voice heardand contribute to RPA PAC.Thank you for supporting RPA PAC. Your contribution will help elect candidates,regardless of party affiliation, who share RPA’s concerns on major issues that affectnephrologists, nephrology practices, and kidney patients.NameFirst Middle LastemployerE-mail Phone Fax (office)Mailing AddressCity State ZipListed below are suggested levels of contribution.Enclosed is my contribution of: ❑ $300 ❑ $600 ❑ $900 ❑ $1,200 ❑ Other❑ My personal check is enclosed, ❑ OR, please bill my personal: ❑ Visa ❑ AM EX ❑ MasterCardAccount #exp. DateName on cardSignatureRPA PAC is a separate, segregated fund established by RPA. Voluntary contributions by individuals to RPA PAC will be used to support candidatesfor public office who demonstrate their belief in the principles to which the profession of nephrology is dedicated. Contributions from corporationsand associations as well as medical practices are prohibited by federal law and cannot be accepted. Contributions to the RPA PAC are NOTdeductible as charitable contributions for federal income tax purposes.Political Action CommitteePlease send personal contributions, made payable to RPA PACc/o RPA:1700 Rockville Pike, Suite 220Rockville, MD 20852Or by fax to: 301-468-3511www.renalmd.org 2011 preliminary program & <strong>registration</strong>155
Page 1 and 2: &RENAL PHYSICIANS ASSOCIATIONannual
Page 3 and 4: &Preliminary ProgramRegistrationHOS
Page 5 and 6: educational objectivesThis activity
Page 7 and 8: preliminary agendafriday, march 187
Page 9 and 10: Saturday, March 19 (continued)• L
Page 11 and 12: advance registration formRegister E
Page 13: RPA MEMBERSHIPThe Renal Physicians

Preliminary Program registration - Renal Physicians Association

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