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1. Name and Good-Will A Member may not use their affiliation with NYSPIA or NYSPIA’s name, contacts, work products, opportunities, or other property to further the Member’s personal or outside activities, business, or employment. A Member may not use NYSPIA’s name in such a way as to lend weight or prestige to a member’s sponsorship of a political party or cause, or in an endorsement of the products, services or causes of any outside company, organization, or partner-ship. 2. Legislative Lobbying and Political Activities The NYSPIA name or logo may not be used for any legislative lobbying or political activities other than those activi-ties undertaken by NYSPIA itself. 3. Publications Either the NYSPIA Executive Board or their designee must approve any publication by a Member if it: • Bears the NYSPIA name • Pertains to the subject matter of NYSPIA’s work • Results from a communication to or by an employee of NYSPIA • Is created through use of any NYSPIA facilities, equipment, or work project 4. Solicitation and Distribution Members may not use NYSPIA property or work time to sell personal products or services or solicit funds. 5. Behavior and Conduct All members shall maintain professional licensure and standing within the medical community. Demonstrate strong moral, ethical, and professional conduct in all dealings with members and the public. Maintain a clear criminal history free from arrests/convictions that would bring discredit upon NYSPIA. Conduct themselves with integrity, respect, and accountability in representing NYSPIA.

I hereby apply to become a member of the New York State Police Investigators Association (NYSPIA) Medical Group. Each of my practice locations, which I am affiliated with, will be identified in this agreement. I will accept the fees listed in NYSPIA member’s insurance schedules as payment for the medical services provided to active and retired members of NYSPIA, as well as their spouses, children, and other eligible household members. I also agree to be available to the NYSPIA Board of Directors and Medical Group as a resource for my medical expertise and/or affiliations to assist in certain circumstances. I understand that the NYSPIA President, Medical Group Chairperson, and/or the NYSPIA Board of Directors reserves the right to terminate my participation in the Medical Group at any time. In the event that I choose to terminate my membership in the NYSPIA Medical Group, I agree to notify the NYSPIA Office in writing 30 days prior to the effective date of the decision. I understand that upon termina-tion of my membership for any reason, by myself or NYSPIA, that I am required to return all materials pertaining to the organization by mail, utilizing a trackable service / carrier, or I may be held liable for these items. I understand if my NYSPIA Medical Group shield, ID card, or vehicle placard is lost or stolen, I will immedi-ately notify the NYSPIA Office in person or by phone. I also understand that my NYSPIA Medical Group shield, ID card, and vehicle placard are non-transferable and may only be used by the individual named on said items. I agree that I will not utilize or attempt to utilize the NYSPIA Medical Group shield, ID card, or vehicle placard to derive benefits, payment, royalties, special privileges or other unethical/illegal returns or exchanges. Additionally, I understand that the NYSPIA Medical Group shield, ID card, and vehicle placard are not to be used to violate or abuse any local, state, or federal laws including those of the NYS Vehicle and Traffic Law. I will adhere to and abide by all correspondences I receive from NYSPIA. In the event, that I wish to advertise my status as a member of the NYSPIA Medical Group, or use the affiliated logo / imagery, I agree to submit such advertisement to NYSPIA for approval. I understand that this agreement does not infringe upon my freedom of choice to accept a patient, nor does it impose any constraints or limitations on my best clinical judgment in treatment. I understand and accept that all applicants are subject to a basic background check prior to membership approval. I understand that the initial NYSPIA Medical Group membership fee of $500.00 includes my first year of NYSPIA Medical Group dues, and the initial application processing fee. I understand that subsequent dues will be billed yearly at $500.00 and are due by March 31st. The current year vehicle placard will be issued to me upon payment of the current year’s dues and the return of the prior year’s vehicle placard to the New York State Police Investigators Association office. My signature below on this application, indicates my understanding, and agreement to accept all provisions set forth in this document.