Tennessee Primary Care Association / Membership Application Form

TPCA
MEMBERSHIP APPLICATION FORM

If you perfer, there is also a print out form
which you may mail.

MEMBERSHIP APPLICATION FORM
Please complete all fields.

You will be billed at the rate indicated in the
Membership Categories Chart below.

If your browser has difficulty displaying this page please use the print out form
or call TPCA's toll free telephone number, 1-800-343-3136 extension 16,
to request a printed copy of the form.  If calling from the Nashville area,
please use 329-3836, extension 16.

Membership Category Membership Dues

Institutional:  Organizations delivering or affecting the delivery of
primary health care services.  Examples are community health centers,
community health agencies, health departments, and hospitals.  An
organization pays dues based on the size of its annual operating budget. Under $99,999.......................................$200
$100,000 - $399,999.............................$800
$400,000 - $999,999..........................$1,200
$1,000,000 - $2,999,999....................$1,600
$3,000,000 and up.........$1,600 plus $500 for each additional $2 million

Individual:  An individual who is supportive of the goals and purposes of the TPCA Supporting..............................................$500
Patron....................................................$100
Contributing............................................$ 50

Associate:  Organizations supporting the purposes of TPCA but not actively involved in the delivery of primary health care services.
Examples are vendors, insurance companies, and pharmaceutical companies. Associate................................................$300

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Name
Title
Organization
E-mail Address Telephone / Fax	Tel: Fax:
Permanent Mailing Address
City/State/ZipCode
Membership Type (choose one)	Individual? Institutional? Associate?
Submission

Membership Category	Membership Dues
Institutional: Organizations delivering or affecting the delivery of primary health care services. Examples are community health centers, community health agencies, health departments, and hospitals. An organization pays dues based on the size of its annual operating budget.	Under $99,999.......................................$200 $100,000 - $399,999.............................$800 $400,000 - $999,999..........................$1,200 $1,000,000 - $2,999,999....................$1,600 $3,000,000 and up.........$1,600 plus $500 for each additional $2 million
Individual: An individual who is supportive of the goals and purposes of the TPCA	Supporting..............................................$500 Patron....................................................$100 Contributing............................................$ 50
Associate: Organizations supporting the purposes of TPCA but not actively involved in the delivery of primary health care services. Examples are vendors, insurance companies, and pharmaceutical companies.	Associate................................................$300