Whether you are an abortion provider; a pro-choice clinician; a student, resident, or fellow; or an advocate, there's a place for you in our community. 1Application Details2References3Agreement4Payment Are you interested in joining NAF as a(n):* Facility or organization that provides abortion care (private and non-profit clinics, Planned Parenthood affiliates, women’s health centers, physicians’ offices, hospitals, and telehealth providers) Individual Pro-Choice Organization Which category best describes you:*If you have questions about which category of membership you should choose, please contact NAF’s Membership Department at membership@prochoice.org. Clinicians in Abortion Care (CIAC) (for Advanced Practice Clinicians (CNM, CPM, LM, PA, NP, RN) or an enrolled student or retiree of these professions) Clinician Provider at a Non-Member Institution Clinician Provider at a Member Institution Allied Health Professionals (individuals who work in other health care fields, including social workers) Canadian Medical Abortion Providing Clinician (individuals who do not provide more than 100 medication abortions per calendar year) Medical student, Resident, or Fellow NAF Associate (non-clinicians who are working in the field of reproductive health, reproductive rights, or reproductive justice) Retiree Member Which category best describes your organization:*Pro-choice Cooperating Organization members provide grassroots organizing, advocacy or coalition building, community or professional education, legal services, public outreach, clinic defense, research, and/or referrals in accordance with NAF’s mission. Reproductive Health Care Organization (RHCO) members provide family planning and/or reproductive health services—not including abortion—in proprietary clinics, nonprofit clinics, feminist clinics, physicians’ offices, and/or facilities affiliated with hospitals. International Organization members provide abortion care, reproductive health care, family planning, grassroots organizing, advocacy or coalition building, community or professional education, legal services, public outreach, clinic defense, research, and/or referrals in accordance with NAF’s mission. Organizations based wholly or in part in North, Central, or South America are not eligible for this category of membership; for information on other membership categories please contact the Membership Department at membership@prochoice.org. Pro-Choice Cooperating Organization Reproductive Health Care Organization International Organization Facility Application DetailsName of Institution: Institution Street Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Institution Mailing Address: Same as street address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Privacy: Please only mail to me in a plain envelope Institution Contact Information:Administrative Telephone Number:Appointments Telephone Number:Toll Free Telephone Number:Fax Number:Emergency Contact Name: First Last Emergency Contact Telephone Number:Facility Manager Name: First Last Facility Manager Email Address: Facility Manager Date of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical Director Name: First Last Medical Director Email Address: Medical Director Date of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NAF Representative Name:The person you have designated to serve as your official NAF representative will be the primary NAF contact and authorized to vote in NAF elections on behalf of your facility. Please note that any future change in designation must be made in writing to NAF. First Last NAF Representative Title: NAF Representative Email Address:* NAF Representative Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Has your facility previously applied for NAF membership? Yes No Date of prior application:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is your facility known by any other name? Yes No Please provide other facility name: Would you like to be listed on the “Find a Provider” section of the NAF Website? Yes No Facility Name to be Listed: Facility Address to be Listed: City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Facility Phone Number to be Listed:Facility Website to be Listed: Facility Governance: Profit Not-for-Profit Facility Ownership: Individual Owner Partnership Business Corporation Not-for-Profit Facility Not-for-Profit Tax Status: Facility EIN: Please list all owners or partners of the facility or corporation and/or a list of members of the Board of Directors:List any physicians who may have oversight or who have written or may write policies and procedures for your facility:Is your facility currently licensed or accredited by any national, state, or local agency?ex: Joint Commission, AAAHC, CLIA, etc. Yes No Please attach any current licensure or accreditation: Drop files here or Select files Max. file size: 50 MB. Agency Name: License #: Date of most recent review:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Services:Is your facility currently providing abortions? Yes No Start date (if any):Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How many total abortions (medication & in-clinic) were performed at your facility in the last calendar year? If your facility has not yet begun providing abortions, how many procedures do you project for the coming year? What days and hours does/will your facility provide abortions?DaysHours Do you provide any of the following non-abortion services? Well-woman and gynecological care Family Planning services Emergency Contraception STD testing and education HIV testing and education Post-abortion counseling Trans care LGBTQ Services Other Please specify for Other: Are you a hospital or in a hospital setting? Yes No Do you provide medication abortion? Yes No Maximum LMP limit (weeks): Do you provide Manual Vacuum Aspiration? Yes No Maximum LMP limit (weeks): Do you provide Machine Vacuum Aspiration? Yes No Minimum LMP limit (weeks): BPD limits for later patients if relevant: Do you offer 2nd Trimester Abortion? Yes No Maximum LMP limit (weeks): Method: D&E Induction Do you offer 3rd Trimester Abortion? Yes No Maximum LMP limit (weeks): Method: D&E Induction Clinician Questionnaire:Please complete for any clinicians providing abortions for your facility.Clinician Name:Graduate School, Degree & Graduation Date:Specialty:Date of Birth:Federal DEA Number:State & License Number:Insurance Carrier: Individual Application DetailsName First Last Pronouns: Name of Employer/School: Name of Employer: Name of College or University: Title: Name of residency/fellowship program (if applicable): Medical School:* Graduation Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Degree Designation: Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Mailing Privacy: Please only mail to me in a plain envelope Telephone:Email Address:* If you work at a Planned Parenthood Affiliate, please use your Planned Parenthood email address.Email Address:* Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920LinkedIn URL Employer/Affiliation Federal DEA Number (for U.S. applicants): State & License Number: CMPA Member (for Canadian applicants)? Yes No College of Physicians & Surgeons Province and License Number(s) NPI (National Provider Identifier) Insurance Carrier: Medical School Degree: Have you previously applied for NAF membership? Yes No Have any medical boards and/or state licensing or regulatory agencies in any jurisdiction in which you have operated filed any actions against you? Yes No Have any medical boards and/or provencial licensing or regulatory agencies in any jurisdiction in which you have operated filed any actions against you? Yes No Please attach documentation of present status of all such actionsAlternatively, you can email documents to membership@prochoice.org. Drop files here or Select files Max. file size: 50 MB. Please describe your involvement with abortion care, reproductive health care, family planning, grassroots organizing, advocacy or coalition building, community or professional education, legal services, public outreach, clinic defense, research, referrals and/or other activities as they relate to abortion, reproductive freedom, and health care:Pro-Choice Organization Application DetailsOrganization Name: Is your organization known by any other name? Yes No Please provide other organization name: Organization Street Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Organization Mailing Address: Same as street address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Mailing Privacy: Please only mail to me in a plain envelope Telephone Number:NAF Representative Name:The person you have designated to serve as your official NAF representative will be the primary NAF contact and authorized to vote in NAF elections on behalf of your facility. Please note that any future change in designation must be made in writing to NAF. First Last NAF Representative Title: NAF Representative Email Address:* NAF Representative Date of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please describe your organization’s goals and services as they relate to abortion, reproductive freedom, and health care: ReferencesPlease provide contact information for three references, preferably individual NAF members or NAF clinics.Reference 1Reference Name:* Affiliated Organization:* Telephone Number:*Email Address:* Reference 2Reference Name:* Affiliated Organization:* Telephone Number:*Email Address:* Reference 3Reference Name: Affiliated Organization: Telephone Number:Email Address: Application AgreementBy authorized signature below, the applicant affirms that all information contained in this application is true and accurate and that any further information provided to NAF in connection with this application will also be true and accurate. The applicant understands that NAF may solicit information from abortion providers who may have relevant knowledge concerning the applicant’s clinical practices, if applicable. The applicant understands that NAF will query the National Practitioner Databank and/or other sources about all U.S. clinician applicants and all physicians performing procedures at the facility submitting this application. Completion of this application does not guarantee membership and the applicant understands that NAF reserves the right to deny membership to any applicant it believes does not meet NAF standards. The applicant agrees that all information NAF furnishes to the applicant during the application process is privileged and confidential and not available to the public. The applicant expressly waives all rights or claims against NAF or any other party arising from such communications. The applicant agrees that all information provided by NAF will be used solely in conjunction with clinic operations and will be made available only to the clinics’ employees, board members, and agents. The applicant understands and agrees to NAF’s application procedures and understands that any offer of membership would be conditioned on promising to comply with any and all policies NAF provides and requires for membership and paying dues in a timely manner as required.Agreement*NAF Confidentiality Agreement NAF regularly distributes to Members a wide range of information (“NAF Information”) related to our mission to enhance the quality and safety of abortion services. 1. Materials covered. NAF Information includes all information distributed by NAF to any or all of our Members, regardless of the form in which it is distributed, and regardless of whether the information is marked as being privileged, confidential, or otherwise subject to this Agreement. This Agreement does not apply to documents that NAF makes available to the public at large or that NAF intends for use by the general public. 2. Use of NAF Information. NAF Information is provided to Members to help enhance the quality and safety of abortion services provided by NAF Members and others. Members may not use NAF Information in any manner inconsistent with these purposes. 3. Disclosure of NAF materials to third parties. NAF Information is intended for the use of NAF Members only. Unauthorized dissemination, distribution, or transmission of NAF Information to persons or organizations that are not affiliated with NAF is strictly forbidden, unless prior written consent is obtained from NAF. 4. Requests for disclosure of NAF Information. Upon learning that NAF materials are or are likely to become the subject of a discovery request in a judicial, legislative, administrative, or other legal proceeding or investigation, Members must: (a) immediately notify NAF, (b) cooperate with NAF (if NAF so requests) in taking all lawful steps to resist or narrow the request or requirement, and (c) if disclosure is required or deemed advisable by NAF, cooperate with NAF in obtaining a protective order or other reliable assurance that the NAF information will receive confidential treatment. 5. Inadvertent disclosure of NAF Information. In the event that a member learns that it has inadvertently disclosed any NAF information to any unauthorized third party, the Member must immediately notify NAF and cooperate with NAF in retrieving the NAF Information or taking other reasonable steps to prevent further unauthorized disclosure. I have reviewed and agree to NAF’s Confidentiality AgreementName of Applicant:* First Last Proof of IdentityPlease upload a photo of your government-issued identification. Max. file size: 50 MB.Authorized Signature:* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Dues PaymentWhich best describes your practice type? Independent Provider Planned Parenthood Affiliate Hospital Provider Doctor's Office Medical Abortion Only Site Application FeeIf our Quality Assurance department determines that your facility is eligible for an in-person Quality Assurance visit as part of your application to NAF, you will be assessed a one-time $1,000 site visit fee along with your membership dues. Price: Application Fee & Onsite Evaluation - Planned Parenthood AffiliateIn order to qualify for Institutional Provider membership, NAF requires that applicants undergo an onsite evaluation. In lieu of an onsite visit, NAF will accept a PPFA accreditation certificate and report. NAF will still offer regular site visits to provide technical assistance as requested by Planned Parenthood affiliates.Payment of a non‐refundable application fee of $250 must accompany each site’s application and PPFA accreditation report.Payment of a non‐refundable application fee of $1,250 must accompany each site’s application only if requesting onsite evaluation by NAF. Price: Onsite Evaluation by NAF Price: Request onsite evaluation by NAF Organization Membership: Pro-Choice Cooperating Organization Price: Organization Membership: Reproductive Health Care Organization Price: Organization Membership: International Organization Price: CIAC Individual Membership Type: Professional Student Individual Membership: Clinicians in Abortion Care (CIAC) Professional Price: Individual Membership: Clinicians in Abortion Care (CIAC) Student Price: Individual Membership: Clinician Provider at a Non-Member Institution$50 non-refundable application fee. If approved for NAF membership, your dues will be $450/year. Price: Individual Membership: Clinician Provider at a Member Institution Price: Individual Membership: Allied Health Professionals Price: Individual Membership: Canadian Medical Abortion Providing Clinician Price: Individual Membership: Medical Student, Resident, or Fellow Price: Individual Membership: NAF Associate Price: Individual Membership: Retiree Price: Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name Credit Card Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Total $0.00 NameThis field is for validation purposes and should be left unchanged.
