DEAPA Membership Application

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Membership Registration Form

July 1, 2008 to June 30, 2009

If you registered on-line last year please log-in

*Indicates a mandatory field

Physician Assistant Information First Name: * Middle Initial: Last Name: *

First Name

Last Name

User ID: * Password: * Re Enter Password: *

User ID

Password

Re-enter Password

Are You Currently a DEAPA Member?* Renewal New

Membership Type*For membership categories click here.

Professional Memberships and Certifications

NCCPA Certified?: Yes No Certification #:	AAPA Member?: Yes No Membership #:
Maine Licensure?: Yes No License #: PA	Other professional affiliations:

Addresses* Indicate your preferred mailing location: Home Work

Home Address:*	Work or School Address:*
	Employer or School: Employer or School name
Street: Street Address	Street: Street Address;
City: City State: Zip: Phone: Fax: Email Address:	City: City State: Zip: Phone: Fax: Email Address:

Other Information: Supervising Physician: PA program from which you received degree:
Year of graduation:

Board of Directors:	Standing Committees:
Please indicate which of the following areas you would be most interested in participating in:
President Vice President Secretary Treasurer Director at Large	Awards Budget and Finance CME Constitution and Bylaws Delegates	Elections Membership Nomination Public Education Publication Other

Suggestions for future CME topics:

Enclosed is my donation to the Susan Vincent Memorial Scholarship fund in the amount of:

*Indicates a mandatory field

Federal Tax Information: Contributions or gifts to DEAPA are not deductible as charitable contributions. Dues payments are deductible as ordinary and necessary business expenses.

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