MD or DO Champion Member Application

Honoree Information

In Honor of In Memory of

Select an option to reveal honoree information fields.

Individual Prefix

First Name *

Last Name *

Email Address

Physician Profile

Degree Type *

Your name will remain confidential. We will not be making our membership public.

First Name *

Last Name *

Street Address *

City *

State *

Postal Code *

Country *

Email *

Phone *

Primary State Licensed *

This information will be used to verify your license.

Website

An https:// must be included in your website address.

States Licensed *

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.

Mentor

Yes No

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.

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

The entire leadership team at Physicians for Informed Consent works on a volunteer basis. Your contribution will go entirely towards achieving our mission. Physicians for Informed Consent is a 501(c)(3) nonprofit organization.