MD or DO Champion Member Application MD/DO Champion MemberDear Doctor,We look forward to your membership! By completing the application below, and submitting the minimum $350 membership dues, you are certifying that you are a Medical Doctor or Doctor of Osteopathic Medicine and that you are opposed to mandatory vaccination laws. As such, you agree to keep matters discussed in our private web forum strictly confidential. It may take over one week for you to be added to the forum, depending on how long it takes us to contact your professional reference. Thank you! Shira Miller, M.D. Physicians for Informed Consent Founder and President (Volunteer Position) Since 2015If you have a discount code, enter it hereApply Membership * MD/DO Champion - $ 350.00 Additional Contribution * Chip in - $ 25.00 $ 50.00 $ 100.00 $ 500.00 $ 1,000.00 $ 5,000.00 $ 10,000.00 No thank you Other AmountOther Amount $ Total AmountHonoree Information In Honor of In Memory of Select an option to reveal honoree information fields. Individual Prefix Mrs.Ms.Mr.Dr. First Name * Last Name * Email Address Physician Profile Degree Type * - select Degree Type -MDDOMBBS Your name will remain confidential. We will not be making our membership public. 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Website An https:// must be included in your website address. States Licensed * AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Specialty * Physician friend? Newsletter? Networking? How did you hear about PIC? Please let us know if you would like to volunteer as a contact person or mentor for physicians in your area. MentorYesNo Professional reference * Please list the name and phone number of a colleague we may contact. Is there anything else you wish to share with us? Oath *I oppose mandatory vaccination laws. 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