New Registration/Renewal Online

 

This form can be used for New Registrations or Existing Member Renewals. You can pay with a check or online with PayPal.
If you are a Student, Membership is Free.

 

Fill out the form below and press submit.
Fields marked with * are required.

 

Membership Type

 

Membership Type:	Choose One Student - FREE Fellow - $35.00 Sustaining - $35.00 Physician - $35.00 *
New or Renew:	Choose One New Renew *

 

 

Member Contact Information

 

AAPA Number:	(Required for Fellow Members Only)
Last Name:	*
First Name:	*
Middle Initial:
Credentials:	*
Home Address:
Address 2:
City:
State:	Please Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Phone 1:	Choose One Home Phone Cell Phone
Phone 2:	Choose One Home Phone Cell Phone
Email Address:	*

 

Work Information

 

Supervising Physician:	*
Name of Office/Worksite:	*
Work Address:	*
Work Address 2:
City:	*
State:	Please Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Zip Code:	*
Work Phone:	*
Work Fax:
Specialty:	* (Endocrinology, Internal Medicine, etc..)
Practice Type:	* (Solo Practice, Group Specialty, etc..)
Other Area of Interest:	(Diabetes, Alternative Medicine, etc..)

 

 

Misc Information

 

Name of PA Program:	*
Graduation Date:	* (or Scheduled Graduation Date)
Are you interested in volunteering with our organization? Yes No
Your areas of interest or leadership experience:

 

 

Contact Preferences

 

Communication:	Email (encouraged) Mail *
Mailing Address:	Home Work *
Payment Choice:	Pay with PayPal Pay by Check
Responsible Party:	Self Office Physician Other
Name on Account:

 

 

 

****Additional Student Information - If you are or will be looking for an endocrine rotation please contact the secretary and provide the following pertinent information: Approximate dates (Month/Year) as well as the City and State of desired rotation. This information will be forwarded via email to our membership.