Membership Info/Application

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WISCONSIN ACADEMY OF PHYSICIAN ASSISTANTS
2008 WAPA Membership Application/Renewal Invoice

Note: Dues year is January-December. Dues are not prorated. Mailing labels and directory information are prepared based on the information supplied.

Title
Name
Work Address
Work Telephone
FAX
E-Mail
Home Address
Home Telephone
Send Mail To:	Home Work
Nationally Certified	Yes No . . . NCCPA#
Wisconsin State Certified	Yes No . . . WI#
AAPA Member	Yes No . . . AAPA#
Date of Graduation from PA School
I prefer to receive the Spectator by mail. Yes No

Method of Payment

Only WAPA members have access to the secure server to allow online credit card transactions.This service is offered in the Members Only section of this website. If you wish to pay via credit card, please print out and fax this form.

If paying by credit card, please note that your statement will read payment made to the State Medical Society of Wisconsin.

If sending form through regular mail, please return this completed form and payment (checks payable to WAPA) to:

Wisconsin Academy of Physician Assistants
702 Eisenhower Drive, Suite A, Kimberly, WI 54136
800-762-8965 · 920-560-5630
Fax: 920-882-3655



WAPA Foundation Contribution

None $15.00 $25.00 $50.00
Other

There are restrictions which impact the tax deductibility of professional dues. A total of 1.6 percent of WAPA's dues for 2003 ($1.76) cannot be deducted as a business expense for federal income tax purposes because of our lobbying activities.


Please check membership category:

Fellow ($125)
Is a fellow member of the AAPA, a Wisconsin PA on the active or inactive MEB list (is currently or was at one time state certified in Wisconsin), or must be a Wisconsin PA who is NCCPA certified and a graduate of an AMA approved PA program.

Member ($125)
Must meet the same qualifications as above except not an AAPA fellow member.

Affiliate ($125)
Is an out-of-state PA or anyone not recognized as a PA by the MEB (not a graduate of an AMA approved PA program or not NCCPA certified) or a physician, nurse, administrator, etc.

Organizational ($125)
Is a clinic, hospital, nursing home, university health service or other institution providing health care.

Student ($10)
This fee covers membership through December 31 of the year of graduation. 

Hardship
Please contact the WAPA office at 800-762-8965 for more information.



I want to join the following committees

Continuing Medical Education
Membership
The Spectator
Constitution & Bylaws
Professional Wellness
Professional Practice
Legislative & Governmental Affairs
Public Relations
Corporate Relations
Website

IMPORTANT
Type of Patient Care

035 - Allergy
036 - Anesthesiology
037 - Cardiology
038 - Dermatology
039 - Endocrinology
040 - Emergency Medicine
041 - Family/General Practice
042 - Geriatrics
043 - Immunology
044 - Industrial/Occupational
045 - Internal Medicine/General
046 - Internal Medicine/Subspecialty
047 - Neurology
048 - Obstetrics/Gynecology
049 - Oncology
050 - Orthopedics
051 - Otolaryngology
052 - Pathology
053 - Pediatrics/General
054 - Pediatrics/Subspecialty
055 - Surgery
056 - Urgent Care
062 - Other

© Wisconsin Academy of Physician Assistants | 702 Eisenhower Dr, Ste A | Kimberly, WI 54136
Tel: (800)762-8965 | Fax: (920) 882-3655
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