Pennsylvania, Midwife, Midwives, CNM, Nurse Midwife, Childbirth educators, Legislation, women's health, natural birthing

Membership

Pennsylvania Association of Licensed Midwives (PALM) MEMBERSHIP APPLICATION - 2009 Click HERE to Download PDF version
PALM MEMBERSHIP#:	(WILL BE ASSIGNED TO YOU)
NAME:	CNM / SNM / OTHER:
ADDRESS:	CITY: STATE: ZIP
COUNTY:	PHONE #: EMAIL:
PRACTICE NAME:	ADDRESS:
CITY:	STATE: ZIP CODE:
COUNTY:	BUSINESS PHONE #: EMAIL:
CHECK HERE:	IF YOU DO NOT WANT YOUR PRACTICE INFORMATION LISTED IN A PALM DIRECTORY
PA MIDWIFERY LICENSE #:	PALM DISTRICT (check one): NORTHWEST NORTHEAST SOUTHWEST CENTRAL SOUTH CENTRAL SOUTHEAST
MEMBERSHIP CATEGORIES:	ACTIVE (PA Licensed Midwives): (Voting members): YEARLY $150 LIFETIME $2250 AFFILIATE: (Non-voting members): STUDENT $37.50 ASSOCIATE $112.50 FRIEND $112.50
MEMBERSHIP DUES:	$
DONATION for Legislative efforts:	$
DONATION for Organizational needs:	$
**TOTAL AMOUNT:	$
PAY BY MAIL:	PRINT AND MAIL IN COMPLETED MEMBERSHIP APPLICATION. MAKE CHECK PAYABLE TO: PALM & MAIL TO: PALM (att. Treasurer)1124 BEVERLY RD. JENKINTOWN, PA 19046
PAY ONLINE:	PAID WITH PAYPAL. PRINT AND MAIL IN COMPLETED MEMBERSHIP APPLICATION MAIL TO: PALM (att. Treasurer) 1124 BEVERLY RD. JENKINTOWN, PA 19046
** Contributions or gifts to PALM are not tax-deductible as charitable contributions; however, some portion of membership dues may be tax-deductible as ordinary and necessary business expenses.