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Member Interest Form

Note: Fields marked with * are required.

Name *
Address *
City*
State*
Zip*
Email*
Specialty/ Sub-specialty

Please check all that are applicable:

Membership Status:

Master
Fellow
Member
Associate
Student

Serve on Committees:

Nominations: Governor's Council, Committee
Members, Member Recruitment
Credentials
Finance
Associate/Medical Student
Health and Public Policy
Awards: Laureate, Master Teacher, Distinguished Internist
Program: Annual Chapter Meeting
Diversity

Areas of Interest:

Clinical Vignette Competition

Mentoring
Judging

Organize group or round table discussions
Host special social/networking events
Moderate health/medical sessions at Chapter Annual Meeting
Present/lead discussions at Associate/Student educational activities
Assist with recruitment
Submit articles for ACP Iowa Chapter Newsletter

Advocacy

Serve on legislative advisory boards
Contact legislators on behalf of membership
Be a key contact person on a specific legislative topic
Topic

Regulatory

Monitor/comment on rule making
Serve on regulatory advisory boards
Meet with third party payor representatives e.g. health plans, Medicare