Veteran Affairs Physician Assistant Association

Membership Application

Name:

Facility:

Facility Address:
Facility City: Facility State Facility Zip:
Facility Telephone: Ext: Work Email:

Home Address:
Home City: Home State: Home Zip:
Home Telephone: Home Email:

Cell Phone: (will aid us in finding you at the conferences)

ALL mail will be sent to the member's HOME mailing address, so please be complete.

NEW MEMBER
RENEWAL
Year Joined:

Type of Membership:

	$750 Life Member	A Single Payment via check or credit card for Lifetime 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	Any student enrolled in an ARC-PA accredited PA program.

AAPA Member: Yes No
AAPA Membership #:

Please mark one for payment method.
Check: $750 for Lifetime Dues (This application must be printed out and mailed with check/MO to address below)
Check: $75 for Annual Dues (This application must be printed out and mailed with check/MO to address below)
New Payroll Deduction : $3 per pay period (See "Note" below)
NOTE: ALL NEW Payroll Deductions MUST click on this link print the instructions and take them to their VA Payroll Office to set up the Payroll deduction - This is NOT automatically done through our website! You must do it at your local VA center.
Continued Payroll Deduction : $3 per pay period (To remind us you are still choosing this form of payment)
SSN (last four only) (Required for ALL payroll deductions to give proper credit.)
Credit Card (check one)

___	VISA
___	MASTERCARD

Name on credit card

Credit card number Secure three

Expiration date (Mo-Yr) or (Mo-Da-Yr) Amount $ Life members change this to $750

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 Amount: $

Dues Amount: $

Total Check or Credit Card $

To print to your slave or default network printer

Print your form first if you want a copy for your files, then hit the submit button to send to VAPAA.

Press only once to avoid duplicate submission When you've completed sending to us, Reset the form to insure your information is safe.

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.) DO NOT EMAIL ANY FORMS!

MEMBERSHIP HOTLINE... 1-866-828-2722

Thank You for being a member!