PCICS Membership Application

CONTACT INFORMATION
All fields required
First Name:
Last Name:
Middle Initial:
Degree:
MD DO PhD MD-PhD PA RN NP RRT APN Other:
Preferred Mailing Address:
City:
State:
Country:
Zip/Postal Code:
Billing Address:
Check this box if Billing Address and Mailing Address are the same.
City:
State:
Country:
Zip/Postal Code:
Home Phone:
Work Phone:
Ext.
Fax:
Email:
Secondary Email:
Date of Birth:
/ / (mm/dd/yy)
Type of Practice:
Private University Government Other
Hospital Affiliation:
University Affiliation:
Academic Degrees & Other Professional Certification With Dates:
Specify residencies and fellowships completed with year (or year of anticipated completion):

 

 
MEMBERSHIP TYPE
Cost based on country and category Tier 1 Tier 2 Tier 3 Tier 4
Physicians $150 $75 $30 $5
Nurses, Other Non-Physician Medical Personnel $100 $50 $20 $3
Find your Tier in this list
Rates for your membership category are automatically calculated.
I Hereby Make Application For:
PHYSICIANS TRAINEE / RESIDENT / FELLOW
(Nurses, Other Non-Physician Medical Personnel rate)
NURSE / ALLIED HEALTH
(Nurses, Other Non-Physician Medical Personnel rate)

 

ADDITIONAL INFORMATION
For the following questions check all that apply, or "NA" if none apply.

Specialty

Anesthesiologist
Cardiac Cath Lab Nurse
Cardiac Cath Lab Nurse Practitioner
Cardiac Nurse
Cardiac Nurse Practitioner
Cardiovascular Surgeon
CICU Nurse
CICU Nurse Practitioner
ECMO Specialist
Pediatric Cardiac Intensivist
Pediatric Cardiologist
Pediatric Intensivist
Pediatrician
Perfusionist
Pharmacist
PharmD
PICU Nurse
PICU Nurse Practitioner
Respiratory Therapist
Other

Where do you work?

CICU   CVICU   PICU   NICU   Cardiology step down unit   Cardiology Floor   Pediatric Floor   NA

Where are cardiac intensive care patients cared for in your hospital?

CICU   CVICU   PICU   NICU   NA

In your institution, how many beds are there in each unit?

CICU 
CVICU 
PICU 
NICU 

Would your hospital be interested in having a link to its website on www.pcics.org?

Yes No

Unsubcribe to Industry Related Notifications?

Yes No

 

PAYMENT OPTIONS

Promo Code
If you are supplying a promo code, please make sure you have selected a membership type
and verify your promo code by selecting the "Verify Code" button before submitting your application.
 
Promo Code:

 

Card Type:
American Express Discover MasterCard Visa
Name printed on card:
Card Number:
Security Code:
Expiration Date:
/
Card Address:
Card Zip Code:

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