Committee Membership Form
ACP Illinois Chapter - Committee Membership Form
Please print and return this insert. If you served in the past and are interested in continuing, please notify us. Indicate your choices by numbering 1,2,3 in order of preference with 1 being your first choice.

Committees: I am interested in the following:

_____ Health and Public Policy
_____ Legislative Affairs
_____ Public Health
_____ Domestic Violence
_____ Gun Violence
_____ Professionalism/Ethics
_____ Membership Enhancement
_____ Medical Student Activities
_____ Informatics-Newsletter
_____ Other

 

Name
 

Address
 

 

 

City State Zip
 

 

 

Daytime Phone Home Phone Fax
 

Email address

Northern Illinois, return to:
Warren W. Furey, MD, FACP
2525 So. Michigan
Chicago, IL 60616

Downstate Illinois, return to:
David Steward, MD, FACP
P.O. Box 19230
Springfield, IL 62794

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