CANDIDATE MEMBERSHIP Application * Items in red denote required fields. Your Name* Email Address* Organization* Office Contact Office Address* City*     State* Zip*  Office Phone* Office Fax  Degree* Subspecialty* Florida License No.* Date of Birth* Spouse's Name  Voluntary Contributions: FOPAC (Florida Orthopaedic Political Action Committee) - Dues Amt: $50.00 Would you be interested in serving on a committee? If so, please select from the following: Legislation Communications FOPAC (Florida Orthopaedic Political Action Committee) Medical Economics Membership Program Sports Medicine Ethics Do you have a specific issue or interest that you would like to see the Society address? I am interested in serving as a key contact to  the following legislators: Credit Card Type* VISA MasterCard Credit Card  Number* Credit Card Expiration* Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018   Comments Please Note that the Revenue Reconciliation Act of 1993 states that association dues used for lobbying activities are not deductible as a business expense. As a result 15% of FOS membership dues and 100% of the voluntary legislative action contributions for 2004 cannot be deducted as a business expense for federal income tax purposes.  PLEASE NOTE: For Candidate membership renewal, the above credit card will be charged $50.00. For voluntary contributions to FOPAC (Florida Orthopaedic Political Action Committee), $50.00 will be charged. Registration rates are non-refundable. If you have any questions, please call (813) 948-8660 News & Events  |  Annual Meeting  |  About FOS Become a Member  |  For Our Members  |  For Our Patients Contact FOS  |  Links  |  Sitemap  |  Home ©2009 FLORIDA ORTHOPAEDIC SOCIETY. All Rights Reserved.