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Membership Application Form
PLEASE PRINT OR TYPE
Membership Application Date________________________________________
Name
_________________________________________________________________________________________________
Title
__________________________________________________________________________________________________
Home Address
__________________________________________________________________________________________
City_______________________________________________________State
_______________ Zip ______________________
Home Phone (
) ____________________________ Home E-Mail
Address__________________________________________
Work Street Address
______________________________________________________________________________________
City_____________________________________________________State
____________________Zip_____________________
Work Phone (
) ____________________________
Work E-Mail
________________________________________________
Employer ____________________________________Specialty
____________________________________________________
PA Program graduated from ________________________________________________
Year Graduated________________
Please send written correspondence to:
(circle one)
HOME WORK
Please send email to:
(circle
one)
HOME WORK
It is best to contact
me by phone at:
HOME WORK
Would you like to serve on the Board/Committee?____YES ____NO ____
I WANT TO LEARN MORE, CONTACT ME.
Would you like
to serve as an RPACNY volunteer? ___YES ____NO ____
I WANT TO LEARN MORE, CONTACT ME.
What CME Topics
would you like to see presented by RPACNY at future dinner meetings and/or
conferences?
________________________________________________________________________________
ANNUAL DUES ENCLOSED
(RPACNY Membership Year runs from June
1-May 31)
_____Graduate PA $25.00 _____Student
$10.00 PA Scholarship Donation $__________________
Please make your check payable to:
Regional Physician Assistants of Central New York
Mail your application and check to: RPACNY P.O. Box 311,
Syracuse, NY 13206
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