National Association of Free Clinics(NAFC)

MemberShip Application

Please Enter All Required(*) Informations :

*Clinic Name

*Federal EIN

*Mailing Address

*City

*State

*Zip + 4

*Phone

*Fax

*Executive Director

*EMAIL [PLEASE print clearly & LIST ALL RELEVANT including those where drug donation offers are to be sent]

*Are you interested in ordering goods including diabetic supplies through our website Free Clinic Link®?

ORGANIZATIONAL INFORMATION CHECKLIST
(please attach to initial application):

	*Mission statement
	*IRS 501(c)(3) letter of determination
	*Current operating budget
	OPTIONAL: Board roster with member affiliations
	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)

ATTESTATION AND REMITTANCE OF DUES

By my signature below, I attest that I verified compliance with NAFC membership eligibility criteria. All of the information contained in this application and accompanying documents is true to the best of my knowledge.

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


SIGNATURE:

2008 NAFC Dues Schedule:
Current Operating Budget	Dues
0-$100,000	$100
$100,001-250,000	$200
$250,001-500,000	$350
$500,001-750,000	$750
$750,001-1M	$1000
$1,000,001-3M	$1500
$3,000,001-4,999,999	$2,000
$5 million +	$3,500

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