Veteran Affairs Physician Assistant Association

Membership Application

Name: ______________________________________________________________________

Facility: _____________________________________________________________________

Address: ____________________________________________________________________

Business Telephone: __________________________   Email: _________________________

Home Address: _______________________________________________________________

Home Telephone: _____________________________  Email: _________________________

I prefer to have VAPAA mail sent to my:  ____Work Address    ____  Home Address

_____NEW MEMBER      _______RENEWAL            Year Joined: _____________

 Type of Membership:

____$75 Fellow                            A practicing PA who is also a fellow member of AAPA.

____$75 Founding Fellow             A VAPAA fellow member in good standing prior to 11/1/91

____$75 Associate                      A VAPAA member who is not a fellow member of AAPA

____$75 Affiliate                         A non-PA supporter (RN, MD, hospital, pharmaceutical rep).

____$5 Associate Student             A student enrolled in an ARC-PA accredited PA program.

AAPA Member:    Yes____   No____     AAPA Membership #: _______________________

Please mark one for payment method.

____Check /Money Order: $75
____New Payroll Deduction: $3 per pay period (Call the VAPAA office or check the web page for instructions in how to enter the necessary information into HRLinks and return this renewal form.)
____Continued Payroll Deduction: $3 per pay period (Return this renewal form to the main office.)
SSN (last four only)______ (Required for all payroll deductions to give proper credit.)
____Credit Card (circle/check one) ____VISA,  ____MASTERCARD;   
Name on credit card ____________________________________

Credit card number _____________________________________

Expiration date ________               Amount ____________________

DO NOT EMAIL THIS FORM. EMAIL IS NOT SECURE. If you do so, VAPAA can NOT be responsible for any idendity theft or misuse of your personal information. Protect yourself and your family's financial future! FAXing is secure to our number below.

_____ I DO NOT wish to have my name printed in the membership directory.

Additional donations can be made to VAPAA by check or credit card. Donations cannot be made via payroll deduction. Please give my additional donation to:

LEGISLATIVE FUND __________  OTHER ______________________________________

Donation:                                  $__________________

Dues:                                        $__________________

Total Check or Credit Card            $__________________

SEND PAYMENT TO:  MAIL: VAPAA, PO Box 128, Iron Mountain, MI 49801

Or   FAX: VAPAA, Attn: VAPAA --- 1-906-774-1839

(ONLY credit card and payroll deduction may be FAXed.)

MEMBERSHIP HOTLINE. 1-866-828-2722