New COA Member Application

First Name *

Middle

Last Name *

Designation *

NPI Number *

Medical Group Name

Office Street Address (No P.O. Box please) *

City *

State *

Zip Code *

E-Mail: *

Phone Number *

Cell Phone

Fax Number

Office Webpage

Office Manager

Office Manager Email Address

Practice Setting *

Please Choose Appropriate Dues Category

Dues Subscription *

$450 Active Member

$400 Semi-Retired-65 years of age or older and working 20 hours per week or less (treatment or medical-legal)

$225 Young Orthopaedist -Young Orthopaedists must be in their first two years of practice post fellowship training.

$275 Orthopaedist in Active Duty in the Military

$275 Research Associate

$125 Resident or Full-Time Fellow

$225 Life Member/Retired-Life/Retired: Must be Active Member 65 years of age or older and completely retired from practice of any type including medical-legal evals. This would not include uncompensated care.

$0 Inactive—Active Member with temporary disability. Send a letter explaining disability.

Do you want to contribute an extra amount to COA's Political Action Committee?
A $500 contribution gains you membership in the Regency Club. As a member of the Regency Club, COA will help you develop meaningful lines of communication with your local legislators.

$100 - Contribution

$150 - Contribution

$200 - Contribution.

$500 - Regency Club

COA Membership requires that at least 90% of your professional activity must be in the field of Orthopaedic Surgery.

* A $100 contribution to OPAC - COA's Political Action Committee is automatically included in COA membership dues. OPAC moneys are used to support California elected officials who serve on key legislative committees and have supported COA's viewpoints on legislation. Your membership also includes a $20 contribution to the AAOS PAC.

PLEASE NOTE: Payments/Contributions to COA are not tax deductible as charitable contributions for federal income tax purposes. Due to federal laws limiting the tax deduction of membership dues paid to organizations involved in lobbying activities, 17% of your dues payment to COA may not be deducted as a business expense.

Contributions to the Political Action Committees are optional.

Remove my COA OPAC Contribution - $100