Central Florida Pediatric Society

							                  MEMBERSHIP APPLICATION

Name: _______________________________________________________________

Practice Name or Hospital Affiliation: __________________________________

______________________________________________________________________

Office Address:___________________________________Suite:_______________

City:_________________________________________________Zip______________

Office Phone:__________________________Fax:___________________________

E-mail Address: _______________________________________________________

If you would prefer mailings to be sent to another address,
please give us that address:

        Address:___________________________________Suite:______________

        City:________________________________________Zip______________


Online www.cfpedsoc.org Pay Pal Confirmation #: ___________________________
     or
Return this form along with your $80 check made payable to:

                          Central Florida Pediatric Society
                         c/o 1890 State Road 436, Ste 215
                               Winter Park, FL 32792

                        Heather J. Hill, Executive Director
                            (407) 678-4040, ext 114
                            cfpedsoc@gmail.com
                               fax: 407-678-6935