Application - Pay by Credit Card

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Membership Types

Application - Pay by Check

Updated: 7/15/2004

Please fill out the application and submit it. Then return to the application page and click on Pay with Credit Card and fill out that information and submit it.

Thank you.

Application

Fellow Associate Affiliate Sustaining Supervising Physician Team Military Student

Please enter your full name (First, Middle,Last):

PA-C PA PA-S Other - please specify:

Please check preferred mailing address:
Home Office

Home Mailing Address

Office Mailing Address

Home Phone

Office Phone

Fax

Email:

Specialty:

Previous TAPA Member? Yes No

Do you practice at a site that is located in a county of 50,000 or less? Yes No

PA Program Attended:
Graduation Date (mm/dd/yyyy):

NCCPA Certification Date: Certification #:

AAPA Member? Yes No AAPA #:

I do not wish to be listed in the TAPA online directory.

We encourage you to serve on one of TAPA's committees: CME, Membership, Professional Practice, Legislative Affairs, Rural Health, Elections, Finance, Peer Assistance, Public Relations, or Student Affairs. Yes No

If yes, which committee?

Pay By Credit Card

Pay by Credit Card

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