Membership Application

First Name

Last Name

Designation (MD, PhD, APRN, etc.)

Personal Address

Street Address

Apt/Suite

City

State

Postal / Zip Code

Organization

Organization Name

Street Address

Apt/Suite

City

State

Postal / Zip Code

Phone

Select the Type of Annual Membership

Group: Licensed physicians and allied health professionals including but not limited to registered nurses,nurse practitioners, clinical nurse specialists, pharmacists, physician assistants, administrators, socialworkers, and office managers in an oncology practice or university. Dues: Up to 10 physicians $750(Small), 11-25 physicians $1,000 (Medium), 26+ physicians $1,500 (Large). All affiliatedallied health professionals are complimentary. Regular: Licensed physician caring for patients with cancer. Dues: $100. Allied Health Professional: Healthcare staff person including but not limited to registered nurse,nurse practitioner, clinical nurse specialist, pharmacist, physician assistant, administrator, socialworker, and office manager. If affiliated with a Group, Dues: Complimentary. If notaffiliated with a Group, Dues: $50. Fellow: Physician enrolled in subspecialty training program to care for patients with cancer.Dues: Complimentary. Retired: Former physician or allied health professional who is no longer practicing.Dues: Complimentary.

If you indicated "Group" above please select which Group from the options below, or start a New Group.

Virginia Cancer Institute New Group