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. 1 Application Details 2 References 3 Agreement 4 Payment 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 Details Name of Institution: Institution Street Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Institution Mailing Address: Same as street address Street Address Address Line 2 City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed 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: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Medical Director Name: First Last Medical Director Email Address: Medical Director Date of Birth: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 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: * Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Has your facility previously applied for NAF membership? Yes No Date of prior application: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Is 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 Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed 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: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Facility Services: Is your facility currently providing abortions? Yes No Start date (if any): Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 How 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? Days Hours 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 Details Name 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: * Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Degree Designation: Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland 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: * Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 LinkedIn 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 actions Alternatively, 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 Details Organization 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 Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Organization Mailing Address: Same as street address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland 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: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Please describe your organization’s goals and services as they relate to abortion, reproductive freedom, and health care: References Please provide contact information for three references, preferably individual NAF members or NAF clinics. Reference 1 Reference Name: * Affiliated Organization: * Telephone Number: * Email Address: * Reference 2 Reference Name: * Affiliated Organization: * Telephone Number: * Email Address: * Reference 3 Reference Name: Affiliated Organization: Telephone Number: Email Address: Application Agreement By 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 Agreement Name of Applicant: * First Last Proof of Identity Please 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 Payment Which best describes your practice type? Independent Provider Planned Parenthood Affiliate Hospital Provider Doctor's Office Medical Abortion Only Site Application Fee If 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 Affiliate In 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 Express Discover MasterCard Visa Supported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 Security Code Cardholder Name Credit Card Billing Address * Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Total $0.00 Email This field is for validation purposes and should be left unchanged.