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)
Please check below and provide check for total amount.
_____Graduate PA
$25.00 _____ Graduate PA $40.00 for 2 years
_____Student $10.00
PA Scholarship Donation $_________
PACNY Annual Charity 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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