Wyoming Association of Physician Assistants

Membership Application

(Print this form and fill out)

Name: __________________________________________________________

Address: ________________________________________________________

Bus Phone: _____________________ Home Phone: ____________________

Fax: _________________ Email Address: _____________________________

WY PA No: ____________ NCCPA No: ____________ AAPA No: ____________

Physician Sponsor: _______________________________________________

Physician Address: _______________________________________________

Physician Phone: ________________________________________________

PA Program: ___________________________ Date Graduated: ___________

Other Chapter Memberships: _______________________________________

Committee Interest: ______________________________________________

Signature: ______________________________________________________

Annual Dues

Cost

Membership Fee:

$ ________

Fellow Membership (AAPA Member)

$80.00

Donation:

$ ________

Associate Members (Non-AAPA Mem)

$80.00

Total:

$ ________

Affiliate Membership

$60.00

Student

$10.00

Contributions or gifts to the WAPA are not deductible as charitable contributions for federal tax purposes. However, dues payment maybe deductible by members as an ordinary and necessary business expense.

Mail with payment to: Attn: WAPA, P.O. Box 4009, Cheyenne, Wyoming 82003

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This page last updated: 10/08/2006

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