Membership Info/Application

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>Printable 2010 Membership Application

 

WISCONSIN ACADEMY OF PHYSICIAN ASSISTANTS
2010 WAPA Membership Application/Renewal Invoice

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

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

I am interested in serving on the following committee(s):

Continuing Medical Education
Diversity
Legislative & Governmental Affairs
Membership
Nominations & Elections
Professional Practice
Professional Wellness
Public Educaiton/Relations
Standing Rules & Policies
the Spectator
Website

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 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


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.

School Attending:
Year of Graduation:

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

© 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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