American College of Physicians. State Disclosure Requirements

Transcription

1 American College of Physicians State Disclosure Requirements Solicitation Language updated February 2015 and Valid Through Date: February 2016 Chapter Alabama Disclosure Message organization, and is an agent of the Alabama Chapter of the ACP, which is also a 501(c)(3) organization. The Alabama Chapter of the ACP is located at P.O. Box 1900, Montgomery, AL ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Alabama Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Alabama Chapter of the ACP, the ACP is located at 190 North the Alabama Chapter of the ACP and their activities as well as a Alaska Voluntary contribution to the Alaska Chapter of ACP. make a 100 percent tax-deductible charitable contribution to the Alaska Chapter of ACP to support of the chapter's student activities and the chapter's annual meeting. As the Alaska Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Alaska Chapter of ACP is tax deductible and will be used to support the activities listed above. Arizona organization, and is an agent of the Arizona Chapter of the ACP, which is also a 501(c)(3) organization. The Arizona Chapter of the ACP is located at 810 West Bethany Home Road, Phoenix, AZ ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Arizona Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Arizona Chapter of the ACP, the ACP is located at 190 North ACTIVE v1 03/24/2015 4:03 PM

2 the Arizona Chapter of the ACP and their activities as well as a Arkansas California Northern (THE UNIFORM STATEMENT MUST BE IN 10 POINT FONT) organization, and is an agent of the Arkansas Chapter of the ACP, which is also a 501(c)(3) organization. The Arkansas Chapter of the ACP is located at 810 W. Bethany Home Road, Anthem, AZ, ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Arkansas Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Arkansas Chapter of the ACP, the ACP is located at 190 North the Arkansas Chapter of the ACP and their activities as well as a Voluntary contribution to the Northern California Chapter of ACP. make a 100 percent tax-deductible charitable contribution to the Northern California Chapter of ACP in support of the Chapter's medical student and residents/fellow members attendance at local and national ACP meetings. As the Northern California Chapter's agent for this solicitation, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Northern California Chapter of ACP is tax deductible and will be used to support the activities listed above. Southern CA 1 (THE UNIFORM STATEMENT MUST BE IN 10 POINT FONT) Voluntary contribution to the Southern California 1 Chapter of ACP. American College of Physicians (ACP) members may elect to make a100 percent tax-deductible charitable contribution to the Southern California 1 Chapter of ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As the Southern California 1 Chapter's agent for this solicitation, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Southern California 1 Chapter of ACP is tax deductible and will be used to support the activities listed above. ACTIVE v1 03/24/2015 4:03 PM 2

3 Southern CA 2 (THE UNIFORM STATEMENT MUST BE IN 10 POINT FONT) Voluntary contribution to the Southern California 2 Chapter of ACP. American College of Physicians (ACP) members may elect to make a 100 percent tax-deductible charitable contribution to the Southern California 2 Chapter of the ACP in support of that Chapter's sponsorship of medical student and resident/fellow member activities including poster competition, travel to Leadership Day, and the Internal Medicine Meeting for the national Poster Competition. Resident/Fellow Resident/Fellow As the Southern California 2 Chapter's agent for this solicitation, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Southern California 2Chapter of ACP is tax deductible and will be used to support the activities listed above. Southern CA 3 (THE UNIFORM STATEMENT MUST BE IN 10 POINT FONT) Voluntary contribution to the Southern California 3 Chapter of ACP. American College of Physicians (ACP) members may elect to make a 100 percent tax-deductible charitable contribution to the Southern California 3 Chapter of the ACP in support of that Chapter's medical students and resident/fellow members.. As the Southern California 3 Chapter's agent for this solicitation, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Southern California 3 Chapter of ACP is tax deductible and will be used to support the activities listed above. Colorado (THE UNIFORM STATEMENT MUST BE IN 10 POINT FONT) Connecticut Colorado residents may obtain copies of registration and financial documents from the office of the Secretary of State by contacting the Licensing Division at ext 6487 or on the web at for obtaining such documents from the Secretary of State. organization, and is an agent of the Connecticut Chapter of the ACP, which is also a 501(c)(3) organization. The Connecticut Chapter of the ACP is located at 30 Dwight Drive, Middlefield, CT ACP members may elect to make a 100 percent tax- ACTIVE v1 03/24/2015 4:03 PM 3

4 deductible, charitable contribution to the Connecticut Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Connecticut Chapter of the ACP, the ACP is located at 190 North the Connecticut Chapter of the ACP and their activities as well as a Delaware organization, and is an agent of the Delaware Chapter of the ACP, which is also a 501(c)(3) organization. The Delaware Chapter of the ACP is located at 812 Rodney Avenue, Front Royal, VA ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Delaware Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Delaware Chapter of the ACP, the ACP is located at 190 North the Delaware Chapter of the ACP and their activities as well as a DC Florida (FIRST PART OF STATEMENT MUST BE CONSPICUOUSLY DISPLAYED IN ALL CAPITAL LETTERS) organization, and is an agent of the District of Columbia Chapter of the ACP, which is also a 501(c)(3) organization. The District of Columbia Chapter of the ACP is located at 812 Rodney Avenue, Front Royal, VA ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the District of Columbia Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the District of Columbia Chapter of the ACP, the ACP is located at 190 North the District of Columbia Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (1-800-HELP-FLA) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. Florida Registration No. CH ACTIVE v1 03/24/2015 4:03 PM 4

5 organization, and is an agent of the Florida Chapter of the ACP, which is also a 501(c)(3) organization. The Florida Chapter of the ACP is located at 1000 Riverside Drive, Suite 220, Jacksonville, FL ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Florida Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Florida Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Florida Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently Georgia Voluntary Contributions to the Georgia Chapter of ACP. make a charitable contribution to the Georgia Chapter of ACP in support of that Chapter's expansion of Resident/Fellow and Medical Student activities in the form of scholarships which are used for travel to the annual Internal Medicine Meeting and Leadership Day in Washington in addition to chapter supported educational and networking activities. As the Georgia Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). The ACP Georgia Chapter is located PO Box 1467, Flowery Branch, GA Based upon the Chapter's intended use of this contribution, your contribution to the Georgia Chapter of ACP is tax deductible and will be used to support the activities listed above. Hawaii Voluntary contribution to the Hawaii Chapter of ACP. make a 100 percent tax-deductible charitable contribution to the Hawaii Chapter of ACP to support developing initiatives across the state to promote high quality, cost effective care, with collegiality and goals that are patient focused and reflective of the Internist as the most respected professional committed to maintaining and striving for health in adults. As the Hawaii Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Hawaii Chapter of ACP is tax deductible and will be used to support the activities listed above. ACTIVE v1 03/24/2015 4:03 PM 5

6 Idaho Illinois Northern Illinois Southern organization, and is an agent of the Idaho Chapter of the ACP, which is also a 501(c)(3) organization. The Idaho Chapter of the ACP is located at Cassia Regional Internal Medicine, 3135 East 3300 North,Twin Falls ID ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Idaho Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Idaho Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Idaho Chapter of the ACP and their activities as well as a organization, and is an agent of the Illinois Northern Chapter of the ACP, which is also a 501(c)(3) organization. The Illinois Northern Chapter of the ACP is located at 810 W. Bethany Home Road, Anthem, AZ, ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Illinois Northern Chapter of the ACP in support of that Chapter's programs and activities for early career physician, resident, and medical student members. Resident/Fellow As an agent of the Illinois Northern Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Illinois Northern Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently organization, and is an agent of the Illinois Southern Chapter of the ACP, which is also a 501(c)(3) organization. The Illinois Southern Chapter of the ACP is located at 810 W. Bethany Home Road, Anthem, AZ, ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Illinois Southern Chapter of the ACP in support of that Chapter's programs and activities for young physician, resident, and medical student members, as well as stipends for members to attend Leadership Day. As an agent of the Illinois Southern Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Illinois Southern Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently ACTIVE v1 03/24/2015 4:03 PM 6

7 Indiana Iowa Kansas organization, and is an agent of the Indiana Chapter of the ACP, which is also a 501(c)(3) organization. The Indiana Chapter of the ACP is located at 810 W. Bethany Home Road, Anthem, AZ, ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Indiana Chapter of the ACP in support of that Chapter's medical student and resident activities, which promote interest, leadership, and professionalism in the specialty. Medical students and residents represent the future of Internal Medicine. Resident/Fellow As an agent of the Indiana Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Indiana Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will organization, and is an agent of the Iowa Chapter of the ACP, which is also a 501(c)(3) organization. The Iowa Chapter of the ACP is located at 1200 Pleasant Street, Des Moines, IA ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Iowa Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Iowa Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Iowa Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will organization, and is an agent of the Kansas Chapter of the ACP, which is also a 501(c)(3) organization. The Kansas Chapter of the ACP is located at 4904 Sweetbriar Drive, Sioux Falls, SD ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Kansas Chapter of the ACP in support of advancing the interest of medical students and residents in pursuing Internal Medicine as a career as well as to support Early Career Physicians in their chosen professional focus. Resident/Fellow We continually experience decreasing industry support and your donation will be used to keep the chapter budget from operating at a deficit. As an agent of the Kansas Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives ACTIVE v1 03/24/2015 4:03 PM 7

8 Kentucky Louisiana Maine Maryland at for further information. A full description of the ACP and the Kansas Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently organization, and is an agent of the Kentucky Chapter of the ACP, which is also a 501(c)(3) organization. The Kentucky Chapter of the ACP is located at 210 Buckner Street, Perryville, KY ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Kentucky Chapter of the ACP in support of that Chapter's educational programs for medical students and residents. Resident/Fellow As an agent of the Kentucky Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Kentucky Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will organization, and is an agent of the Louisiana Chapter of the ACP, which is also a 501(c)(3) organization. The Louisiana Chapter of the ACP is located at Attn: Richard Deichmann, 1514 Jefferson Highway, New Orleans, LA ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Louisiana Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Louisiana Chapter of the ACP, the ACP is Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Louisiana Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will be provided upon request. organization, and is an agent of the Maine Chapter of the ACP, which is also a 501(c)(3) organization. The Maine Chapter of the ACP is located at Ani Circle, Estero, FL ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Maine Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Maine Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Maine Chapter of the ACP and their activities as well as a A copy of the current financial statement of American College of Physicians, Inc. and the Maryland Chapter of the ACP is available ACTIVE v1 03/24/2015 4:03 PM 8

9 (STATEMENT MUST BE CONSPICUOUSLY DISPLAYED) Massachusetts by writing 190 N. Independence Mall West Philadelphia, PA or by calling Documents and information submitted under the Maryland Solicitations Act are also available, for the cost of postage and copies, from the Maryland Secretary of State, State House, Annapolis MD 21401, (410) organization, and is an agent of the Massachusetts Chapter of the ACP, which is also a 501(c)(3) organization. The Massachusetts Chapter of the ACP is located 860 Winter Street, Waltham, MA ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Massachusetts Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Massachusetts Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Massachusetts Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will be provided upon request. Michigan MICS No Minnesota organization, and is an agent of the Minnesota Chapter of the ACP, which is also a 501(c)(3) organization. The Minnesota Chapter of the ACP is located at 1043 Grand Avenue, #215, Saint Paul, MN ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Minnesota Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Minnesota Chapter of the ACP, the ACP is located at 190 North the Minnesota Chapter of the ACP and their activities as well as a Mississippi The official registration and financial information of American College of Physicians, Inc. and the Mississippi Chapter of the ACP may be obtained from the Mississippi Secretary of State's office by calling Registration by the Secretary of State does not imply endorsement by the Secretary of State. ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Mississippi Chapter of the ACP in support of the Chapter's continuing support of our internal medicine residents and medical students participation in the regional meeting, national meeting and Leadership Day each year. These early career physicians in training are the future of our chapter and we are committed to supporting them through the ACTIVE v1 03/24/2015 4:03 PM 9

10 Missouri Montana Nebraska efforts of our chapter. organization, and is an agent of the Missouri Chapter of the ACP, which is also a 501(c)(3) organization. The Missouri Chapter of the ACP is located at PO Box 1028, Jefferson City, MO ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Missouri Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Missouri Chapter of the ACP, the ACP is located at 190 North the Missouri Chapter of the ACP and their activities as well as a organization, and is an agent of the Montana Chapter of the ACP, which is also a 501(c)(3) organization. The Montana Chapter of the ACP is located at 3320 Eagle Court, Great Falls, MT ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Montana Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Montana Chapter of the ACP, the ACP is located at 190 North the Montana Chapter of the ACP and their activities as well as a Voluntary contribution to the Nebraska Chapter of ACP. make a 100 percent tax-deductible charitable contribution to the Nebraska Chapter of ACP to support efforts to keep the chapter budget from operating at a deficit, due to decreasing industry support. As the Nebraska Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Nebraska Chapter of ACP is tax deductible and will be used to support the activities listed above. Nevada organization, and is an agent of the Nevada Chapter of the ACP, ACTIVE v1 03/24/2015 4:03 PM 10

11 New Hampshire New Jersey (STATEMENT MUST BE CONSPICUOUSLY PRINTED IN ALL CAPITAL LETTERS) which is also a 501(c)(3) organization. The Nevada Chapter of the ACP is located at 1364 Enchanted River Drive, Henderson, NV ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Nevada Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Nevada Chapter of the ACP, the ACP is located at 190 North the Nevada Chapter of the ACP and their activities as well as a organization, and is an agent of the New Hampshire Chapter of the ACP, which is also a 501(c)(3) organization. The New Hampshire Chapter of the ACP is located at 7 N. State Street, Concord, NH ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the New Hampshire Chapter of the ACP in support of the Chapter's continued support of residents and students.as an agent of the New Hampshire Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the New Hampshire Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will be provided upon request. INFORMATION FILED WITH THE ATTORNEY GENERAL CONCERNING THIS CHARITABLE SOLICITATION AND THE PERCENTAGE OF CONTRIBUTIONS RECEIVED BY THE CHARITY DURING THE LAST REPORTING PERIOD THAT WERE DEDICATED TO THE CHARITABLE PURPOSE MAY BE OBTAINED FROM THE ATTORNEY GENERAL OF THE STATE OF NEW JERSEY BY CALLING AND IS AVAILABLE ON THE INTERNET AT REGISTRATION WITH THE ATTORNEY GENERAL DOES NOT IMPLY ENDORSEMENT. New Mexico organization, and is an agent of the New Mexico Chapter of the ACP, which is also a 501(c)(3) organization. The New Mexico Chapter of the ACP is located at 1432 Sara Way, Rio Rancho NM ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the New Mexico Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the New Mexico Chapter of the ACP, the ACP is located at 190 North ACTIVE v1 03/24/2015 4:03 PM 11

12 the New Mexico Chapter of the ACP and their activities as well as a New York (THIS STATEMENT MUST BE IN BOLD 10 POINT FONT OR ALTERNATIVELY, NO SMALLER THAN THE SIZE PRINT USED FOR THE MOST NUMBER OF WORDS IN THE SOLICITATION) North Carolina (THIS STATEMENT MUST BE IN AT LEAST 9 POINT FONT AND MUST BE MADE CONSPICUOUS BY USE OF ONE OR MORE OF THE FOLLOWING: UNDERLINING, A BORDER OR BOLD TYPE) Upon request, a copy of the latest annual report can be obtained from the American College of Physicians, Inc. (ACP) at 190 North Independence Mall West, Philadelphia, Pennsylvania The New York Chapter of the ACP is located at 744 Broadway, Albany, NY or Office of the Attorney General by writing to the Charities Bureau, 120 Broadway, New York, NY A description of programs and activities can also be obtained directly from the American College of Physicians, Inc. or its local Chapter. Financial information about this organization and a copy of its license are available from the State Solicitation Licensing Branch at (919) The license is not an endorsement by the State. North Dakota Ohio organization, and is an agent of the North Dakota Chapter of the ACP, which is also a 501(c)(3) organization. The North Dakota Chapter of the ACP is located at Altru Health System,, 1000 South Columbia Road, Grand Forks, ND ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the North Dakota Chapter of the ACP in support of that Chapter's educational programs. Resident/Fellow As an agent of the North Dakota Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the North Dakota Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will Voluntary Contributions to the Ohio Chapter of ACP. make a charitable contribution to the Ohio Chapter of ACP in support of the Chapter's member travel to ACP national meetings and Leadership Day as well as to offset member registration fees for the chapter meeting. Resident/Fellow As the Ohio Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Ohio Chapter of ACP is tax deductible and will be used to ACTIVE v1 03/24/2015 4:03 PM 12

13 support the activities listed above. Oklahoma organization, and is an agent of the Oklahoma Chapter of the ACP, which is also a 501(c)(3) organization. The Oklahoma Chapter of the ACP is located at 215 E. 6 th Street, Edmond OK ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Oklahoma Chapter of the ACP in support of that Chapter's medical student and resident members.. As an agent of the Oklahoma Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Oklahoma Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will Oregon Pennsylvania (THIS STATEMENT MUST BE CONSPICUOUSLY PRINTED VERBATIM) organization, and is an agent of the Oregon Chapter of the ACP, which is also a 501(c)(3) organization. The Oregon Chapter of the ACP is located at 3021 NE 72nd Drive, Ste 9, PMB #148, Vancouver, WA 98661,. ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Oregon Chapter of the ACP in support of that Chapter s early career physicians, residents/fellows, and medical students with activities that build careers in internal medicine. Resident/Fellow As an agent of the Oregon Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Oregon Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will The official registration and financial information of the American College of Physicians, Inc. and the Pennsylvania Chapter of the American College of Physicians, Inc. may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania, Registration does not imply endorsement. Voluntary contribution to the Pennsylvania Chapter of ACP. make a 100 percent tax-deductible charitable contribution to the Pennsylvania Chapter of ACP to support in support of that Chapter's abstract and poster competitions for resident and student members of the PA-ACP. Competitions are held annually in all ACTIVE v1 03/24/2015 4:03 PM 13

14 three regions. More than 460 abstracts are received annually. As the Pennsylvania Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Pennsylvania Chapter of ACP is tax deductible and will be used to support the activities listed above. Rhode Island (STATEMENT MUST BE CONSPICUOUSLY DISPLAYED) South Carolina South Dakota organization, and is an agent of the Rhode Island Chapter of the ACP, which is also a 501(c)(3) organization. The Rhode Island Chapter of the ACP is located at 97 Amsterdam Avenue, Warwick, RI ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Rhode Island Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Rhode Island Chapter of the ACP, the ACP is Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Rhode Island Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will be provided upon request. organization, and is an agent of the South Carolina Chapter of the ACP, which is also a 501(c)(3) organization. The South Carolina Chapter of the ACP is located at P.O. Box 11188, Columbia, SC ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the South Carolina Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the South Carolina Chapter of the ACP, the ACP is Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the South Carolina Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will be provided upon request. Voluntary Contributions to the South Dakota ACP. make a charitable contribution to the South Dakota Chapter of ACP in support of efforts to keep the chapter budget from operating at a deficit, due to decreasing industry support. As the South Dakota Chapter's agent for this solicitation, the ACP ACTIVE v1 03/24/2015 4:03 PM 14

15 is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the South Dakota Chapter of ACP is tax deductible and will be used to support the activities listed above. Tennessee organization, and is an agent of the Tennessee Chapter of the ACP, which is also a 501(c)(3) organization. The Tennessee Chapter of the ACP is located at st Avenue South, Nashville, TN ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Tennessee Chapter of the ACP in support of that Chapter's advocacy efforts and resident/fellow/student outreach programs. Resident/Fellow As an agent of the Tennessee Chapter of the ACP, the ACP is located at 190 North Independence Mall West, Philadelphia, Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Tennessee Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will Texas Voluntary contribution to the Texas Chapter of ACP. make a 100 percent tax-deductible charitable contribution to the Texas Chapter of ACP to support medical student and resident programs and activities. Resident/Fellow As the Texas Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Texas Chapter of ACP is tax deductible and will be used to support the activities listed above. Utah organization, and is an agent of the Utah Chapter of the ACP, which is also a 501(c)(3) organization. The Utah Chapter of the ACP is located at 50 N. Medical Drive, #5R218, Salt Lake City, UT ACP members may elect to make a 100 percent taxdeductible, charitable contribution to the Utah Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As an agent of the Utah ACTIVE v1 03/24/2015 4:03 PM 15

16 Chapter of the ACP, the ACP is located at 190 North the Utah Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently Vermont Virginia Washington (MUST BE CONSPICUOUSLY DISPLAYED) organization, and is an agent of the Vermont Chapter of the ACP, which is also a 501(c)(3) organization. The Vermont Chapter of the ACP is located at P.O. Box 1457, Montpelier, VT ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Vermont Chapter of the ACP in of the medical students and residents.as an agent of the Vermont Chapter of the ACP, the ACP is located at 190 North the Vermont Chapter of the ACP and their activities as well as a A financial statement is available upon request, from the Virginia State Division of Consumer Affairs, P.O. Box 1163, Richmond, VA 23218, or by calling Information relating to the registration and financial affairs of the American College of Physicians, Inc. (located at 190 North Independence Mall West, Philadelphia, Pennsylvania ) and the Washington Chapter of the ACP (located at Suite 1100, 2033 Sixth Avenue, Seattle, WA 98121) is available from the Secretary of State, and the toll-free number within Washington is ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Washington Chapter of the ACP in support of that Chapter's medical student, resident/fellow and early career physician activities. West Virginia (STATEMENT MUST BE CONSPICUOUSLY DISPLAYED) Wisconsin West Virginia residents may obtain a summary of the registration and financial documents from the Secretary of State, State Capitol, Charleston, West Virginia Registration does not imply endorsement. organization, and is an agent of the Wisconsin Chapter of the ACP, which is also a 501(c)(3) organization. The Wisconsin Chapter of the ACP is located at 6737 W. Washington Street, Suite 1300, Milwaukee, WI ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Wisconsin Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary ACTIVE v1 03/24/2015 4:03 PM 16

17 care. As an agent of the Wisconsin Chapter of the ACP, the ACP is Pennsylvania You may contact any number of our representatives at for further information. A full description of the ACP and the Wisconsin Chapter of the ACP and their activities as well as a copy of their audited financial statement for the most recently completed fiscal year will be provided upon request. Wyoming ACP members may elect to make a 100 percent tax-deductible, charitable contribution to the Wyoming Chapter of the ACP in support of that Chapter's educational, Resident/Fellow and Medical Student initiatives as well as increased efforts to promote internal medicine and primary care. As the Wyoming Chapter's agent for this solicitation, the ACP is Pennsylvania (Phone: ). Based upon the Chapter's intended use of this contribution, your contribution to the Wyoming Chapter of ACP is tax deductible and will be used to support the activities listed above. ACTIVE v1 03/24/2015 4:03 PM 17