| MEMBER APPLICATION |
Association of Physician Assistants In Psychiatry
(APAP)
C/O Don St.John PA
4968 400th St SE
Iowa City, IA 52240
319-341-9115
319-353-7788 (fax)
don-stjohn@uiowa.edu
MEMBERSHIP APPLICATION |
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LAST NAME____________________________ FIRST NAME____________________________
WORK ADDRESS___________________________________________________________________
CITY_________________________________ STATE___________________ ZIP___________
PHONE_________________________ FAX____________________
E-MAIL________________________________________________________________________
HOME ADDRESS___________________________________________________________________
CITY_________________________________ STATE____________________ ZIP__________
PHONE______________________________________ FAX_________________________________
E-MAIL________________________________________________________________________
I prefer to be contacted at home_______ work________
AAPA MEMBER NUMBER______________________ NCCPA NUMBER______________________
PA PROGRAM YOU GRADUATED FROM______________________________________________
DATE OF GRADUATION_______________________________ YEARS AS A PA____________
YEARS WORKING AS A PA IN MENTAL HEALTH_____________________________________
DEGREE(S)__________________________________________________________________
May we include your name on a mailing list to be given or sold to professional organizations (not for advertising purposes), such as journals, other health care organizations, etc?
YES________ NO__________
Would you be willing to be a preceptor for PA students doing a mental health rotation?
Yes_____ NO_____
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| 2005 MEMBERSHIP FEE (AAPA members) $25.00 |
| 2005 MEMBERSHIP FEE (non-AAPA members) $50.00 |
| 2005 STUDENT MEMBERSHIP FEE $10.00 |
| Don St. John MA, PA |
Looking for information about the APAP contact Don St. John |
| Thank You for Supporting APAP! |
