Association of Family Practice Physician Assistants

---Printable Membership Application---

Please enter your information on this form. Print the form using the "print" button.
Note that items marked with an "*" are required fields.

PERSONAL INFORMATION:

*First Name:

Middle Initial:

*Last Name:

Suffix (ex: Jr., Sr.):

Credentials (ex: PA-C, MPAS):

*Specialty:

*Address Line 1:

Address Line 2:

*City:

*State:

*Zip Code

*Home Phone:

Work Phone:

Cell Phone:

Fax:

*Email Address:

AAPA Membership #
(if known)

PA Program

Graduation Year

AFPPA Membership #
(if a renewing member)

MEMBERSHIP INFORMATION:

*Please select one membership option from the choices below:

Fellow	$85	Graduates of PA Programs approved by the Board and/or persons certified by the NCCPA
Fellow	$200	3 year membership
Fellow	$1,000	Lifetime membership
Fellow	$75	Get 3 people to join and you all receive a $10 discount the first year if application and payment is included in the same envelope
Sustaining	$50	Graduates of PA Programs approved by the Board and/or persons certified by the NCCPA who have chosen not to practice in the PA profession
Student	$25	Enrolled in an accredited Physician Assistant Program
Physician	$50	U.S. licensed physician who wishes to associate with the organization
Associate	$50	Persons engaged in selling products or other services to PAs
Affiliate	$35	Persons who are ineligible for any of the above categories and wishes to associate with the organization and is approved by the Board
		Student Scholarship Fund (optional donation to the Student Scholarship Fund)
		* Total

PAYMENT OPTIONS:

Payment Option:

(Choose One)

Check (payable to AFPPA) Visa MasterCard American Express

Credit Card #:

Name as it appears on Credit Card:

Expiration Date: (mm/yy)

Card Verification Code:

MISCELLANEOUS:

I prefer to have my quarterly newsletter Mailed Emailed

I am willing to do the following: (indicated by a check mark)
     Precept FP PA students
     Mentor FP PA students
     serve on a committee of AFPPA
     Allow a pre-PA student to shadow me
     Be considered to speak at a future AFPPA conference
     Allow my contact information to be released to third parties who market to PAs

Mail or Fax Instructions

Complete form and mail to:	AFPPA 1905 Woodstock Road, Suite 2150 Roswell, GA 30075
Complete form and fax to:	770-640-1095
Payment is due with registration form. If faxing, please include credit card number. To avoid duplicate charges, do not mail registration form if you have already faxed it or submitted it via online registration form.
Make checks payable to AFPPA	(AFPPA'S Tax ID#: 74-2893814)