National Association of Free Clinics(NAFC)

National Association of Free Clinics 2008 State Association Membership Application

Please Enter All Required(*) Informations :

MEMBER INFORMATION :

*User Name :

*Password :

Retype Password :

*Association Name

* EIN

*Mailing Address
Busines Address (if different)

*City

*State

*Zip + 4

*Phone

*Fax

*Executive Director

*Email

Website

ORGANIZATIONAL INFORMATION CHECKLIST
(please attach to initial application):

	* Bylaws
	*IRS 501(c)(3) letter of determination
	*Current operating budget
	*Current membership list
	*Board Roster
	*Most recent annual statistical report
	OPTIONAL: Program brochure or other promotional material, if available

PROGRAM INFORMATION [optional, but useful for NAFC statistical purposes]:

Primary Health Care Services Offered:

	Medical		Dental
	Rx�s		Mental Health

Year Program Incorporated

Number of Patient Visits in Past Year

Number of Unduplicated Patients in Past Year

NUMBER OF VOLUNTEERS AT THIS SITE

Medical Providers
(MD, NP, PA, DO)

Pharmacy Providers
(RPh, Pharmacy Technicians)

Dental Providers
(DDS, RDH, Dental Assistants)

Mental Health Providers
(Counselors, Therapists, LCSW, etc.)

Nurses
(RN, LPN, Medical Assistants)

Others
(health care professionals and lay)

State Association Dues

State Association Dues are $10 per association member organization. Association membership applies only to the state association organization and not its individual members.

Number of Association Members :


2008 NAFC Dues($) :
(Insert the applicable amount from table at right)

SIGNATURE:	TITLE :

Please make your check payable to the National Association of Free Clinics and mail to:

Nicole Lamoureux, NAFC Executive Director

1800 Diagonal Road, Suite 600

Alexandria VA 22314

Phone: 703-647-7427 NLamoureux@freeclinics.us