Associate Member Application Please disable any ad blockers, which might prevent successful form submission.Dear Doctor,We look forward to your membership. By completing the application below, you are certifying that you are a physician and that you are opposed to mandatory vaccination laws.If you wish to attend our private events, speaker seminars, obtain a one-year free membership to AAPS, or participate in the physician's private web forum, please upgrade to a Champion membership.Thank you,Physicians for Informed Consent Membership * MD/DO Free One-Year 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 Amount Honoree 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. 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. 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