Membership Renewal

Subscription Renewal

Invoice#

CARIBBEAN COLLEGE OF FAMILY PHYSICIANS Cash/ Cheque Payment Form

To: The Caribbean College of Family Physicians (CCFP)

Name

Tel

Email Address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date

Cheque No

Bank

CCFP Membership Number:

Territory

Kindly renew my Membership to CCFP, I enclosed a cheque/cash/Card in the sum of:

Cash/ Credit Card/Debit Card

Membership Application

MEDICAL REGISTRATION NUMBER *

DATE *

(M/D/Y)

LAST NAME *

FIRST NAME *

MIDDLE NAME *

DATE OF BIRTH *

MAILING ADDRESS *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

EMAIL ADDRESS *

PHONE *

WORK *

HOME

FAX

PAGER

CELL

DEGREES, DIPLOMAS ETC.

Qualifications *

Institution *

Year *

CURRENT POSITION/ OCCUPATION *

INVOLVEMENT IN FAMILY PRACTICE: *

PART TIME
FULL TIME

INTERESTS

Medical Interests *

Non-Medical Interests *

MEMBERSHIP FEE US$80.00 *

NAME OF REFERRING CCFP MEMBER: *

REFEREE INFORMATION (NOT APPLICABLE TO FOUNDING MEMBERS)

ADDRESS *

PHONE *

YOUR CV’s *

Click or drag a file to this area to upload.

(A copy of your CV’s would be appreciated; also an indication of your willingness to assist with the development of the College and in what aspect.) Copy to 19A Windsor Avenue, Kingston 5, Jamaica, West Indies

Your Degrees/Certificate *

Click or drag a file to this area to upload.

Your Practicing Certificate *

Click or drag a file to this area to upload.

Your Passport size Photograph *

Click or drag a file to this area to upload.

Please Upload Your Receipt *

Click or drag a file to this area to upload.

Payment Agreement *

I’ve made the payment

Once payment is completed, please accept the payment agreement to continue.

Credit Card Authorization Form

To: Caribbean College of Family Physicians

From:

Date:

Country:

Kindly debit my Credit Card as follows:

Initial CCFP Membership Subscription
Renewal CCFP Membership Subscription
CCFP Conference
Other/Date of Conference

# of years:

Kindly state other/Date of meeting:

*****************************************************************************************************************

This serves to authorize Caribbean College of Family Physicians to debit my credit card as follows:

Name:

Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone #:

Amount:

US$/J$

Bank:

Card Type:

Card Number:

Email credit card information to familydoctorsregional@gmail.com

(To facilitate card privacy, please provide the rest of the card number in an email or WhatsApp).

Year of expiration

Email expiration details to familydoctorsregional@gmail.com

Card CVC2 (Mastercard) or CVV2 (Visa) Number:

(Card Validation Code or Card Verification Value – Unique three digit number at back of card)

Special Instructions:

Please call the secretariat at 876-517-6636 for how to make payments via credit card

Signature:

Member Accreditation Form

CARIBBEAN COLLEGE OF FAMILY PHYSICIANS MEMBER ACCREDITATION APPLICATION FORM

This form is for application for Accreditation to the Caribbean College of Family Physicians. You will be required to deliver copies of your CME Certificates to the CCFP Secretariat for final  verification.

I confirm that I have completed 50 hours of CME activities each year or a total of 150 hours for the Triennium (3 years) *

Name *

First

Last

Confirmation of Full Name *

First

Last

Email *

Telephone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Specialty *

Country/Island *

Years in practice *

Number of years accreditation being applied for

Please upload your CME Log Sheet here, or you can send to the CCFP Secretariat by email, then deliver to the CCFP copies of your CME Certificates to the CCFP Secretariat

Click or drag a file to this area to upload.

I confirm that the information and records I have provided are correct and accurate to the best of my knowledge (E&OE)

Option 1

CME Log Sheet

CARIBBEAN COLLEGE OF FAMILY PHYSICIANS CME HOURS REGISTER

YEARS UNDER REVIEW

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Date/Year

CME ACTIVITY

EVENT SPONSOR/HOST

VENUE

CREDIT HOURS

Annual Membership Declaration Form

As we approach the end of the year, it is time for our chapters across the Caribbean to declare their annual membership to the College.

We understand the crucial role that each chapter plays in advancing the field of family medicine in the region, and we greatly appreciate your ongoing commitment and dedication. Your chapter’s participation is essential in fostering collaboration, sharing knowledge, and enhancing the overall impact of the Caribbean College of Family Physicians.

To complete the annual membership declaration process, we kindly request that you provide the information as stated on the form for your chapter:

Please submit the information by January 31^st, as this will enable us to compile a comprehensive report on the collective achievements and contributions of all our chapters in the Caribbean.

Your cooperation is invaluable in strengthening the network of family physicians in the region and advancing the goals of the Caribbean College of Family Physicians. If you have any questions or require assistance during this process, feel free to reach out to us at familydoctorsregional@gmail.com

We appreciate your commitment to the Caribbean College of Family Physicians (CCFP) and kindly request you to complete the Annual Membership Declaration Form for your regional chapter

Chapter Name: *

Chapter Address: *

Chapter Email: *

Chapter President's Name: *

President's Email: *

Chapter Secretary's Name: *

Secretary's Email: *

Total Membership Count: *

Total Paid-Up Members: *

Annual Renewal Dues per member: *

New Dues (amount) per member: *

New Members (Number): *

Upload Membership Register: *

Click or drag a file to this area to upload.

Please upload the membership register document containing the following details for each member: Full Name, Email, Specialty, Telephone Contact.

Upload Chapter Executives: *

Click or drag a file to this area to upload.

President, Vice President, Secretary, Treasurer, and other relevant positions. Please upload a document containing their full names and positions.

Please upload Chapter Activities Report *

Click or drag a file to this area to upload.

• A brief summary of the activities and events organized by your chapter throughout the year.

Please upload Financial Statement: (Optional)

• An overview of your chapter’s financial status, including income and expenses related to College activities.(Optional)

Feedback and Suggestions:

• Any feedback or suggestions that your chapter may have regarding the College’s initiatives, programs, or areas for improvement.

Thank you for your continued support, and for your submission. We will forward your Cess Invoice as soon as we receive your declaration. Please be reminded that CESS is charged on members in good standing for the period the declaration is submitted.