CHINESE AMERICAN PHYSICIANS SOCIETY

Membership Application

NAME: DR./MR./MRS.MS.________________________________________________

MAILING ADDRESS:_____________________________________________________

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TELEPHONE: VOICE______________FAX__________________HOME___________

E-MAIL ADDRESSES:____________________________________________________

BIRTHDATE:_____________MARITAL STATUS:____________SPOUSE:__________

MEDICAL OR GRADUATE SCHOOL:_______________________________________

DEGREE AND YEAR OF GRADUATION:___________________________________

OCCUPATION OR SPECIALTY:__________________________________________

POSTGRADUATE TRAINING AND/OR ACHIEVEMENTS:_____________________

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REFERENCES: List three references preferably current CAPS members. If references are not

CAPS members, please also provide addresses. For Associate Member applicants only,

please write the name of your sponsor (must be an active CAPS member) below:

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Membership Dues: ($50 for Physician Member, $35 for Associate Member)____________

Additional Contributions:______________________ Total Enclosed:_________________

For Internet security reason, please print out this page and mail it with your check payable to CAPS to:

Lawrence Ng, M.D., Exec.Director-CAPS, P.O. Box 3287, San Leandro, CA 94578.

Telephone: (510)357-7077