Pennsylvania Society of Physician Assistants
P.O. Box 128
Greensburg, PA 15601
Phone 724-836-6411
Fax 724-836-4449

PLEASE PRINT THIS FORM THEN COMPLETE AND MAIL WITH YOUR REMITTANCE PAYABLE TO PSPA  OR FAX WITH CREDIT INFORMATION
TO 724-836-4449. PLEASE PRINT CLEARLY.

Name:______________________________________________________
Home Address:_______________________________________________
City / State / Zip:_____________________________________________
Business Address:_______________________________________________
City / State / Zip:_____________________________________________
County:___________ Senate District No.___ House District No.___
Home Phone:( )_____________ Business Phone:( )_________________
E-mail address:_____________________________________________

This membership year extends from July 1 to June 30.
Please check the membership category for which you are applying:

_____ Fellow $100.00 (AAPA member practicing and / or residing in Pennsylvania)
_____ Affiliate $100.00 (non-AAPA member practicing and / or residing in Pennsylvania)
_____ Sustaining $60.00 (PA not practicing in Pennsylvania, or other health professional)
_____ Associate (Hospital, Insurance Company or Group Practice) $170.00
_____ Solo Practice Physician $100.00
_____ Student $30.00 per year or $50 for two years
_____ Non-PA Student $15.00 (individual interested in the exploring the Profession)

PA Program Attended /Attending: __________________________________________________
Year of Graduation:_________________
Current AAPA Membership no.__________________________
State Board No.:____________________
NCCPA Certificate No.:________________
Practice Setting: Urban _____, Rural ______, or Suburban ______
Practice Location: Office_____ Hospital _____, or Other(please specify)____________
Specialty: ______________________________

Signature___________________________________ Date____________

Payment by _____ Check or _____ Credit Card

Card Number: ___________________________________

Card Expiration Date: ______________________________

Card Holder Name: _______________________________

*Hardship category consideration can be made upon written request to the Society
* Dues are deductible as a business expense at 80%.
2-2002*

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