Please print this form and complete it entirely.
Make checks payable to Arkansas Academy of Physician Assistants
Mail check and completed form to the address below.
NAME: __________________________________TITLE: __________________________
I prefer to receive mail at HOME WORK (Please circle one.)
HOME ADDRESS: __________________________________________________________
(Street Address)
_____ FELLOW MEMBER $50/yr
Must be a graduate of an approved PA program or NCCPA certified and a Fellow
member of AAPA. NCCPA # __________ AAPA # ____________
_____ AFFILIATE MEMBER $50/yr
Same as Fellow, but need not be a Fellow of AAPA.
Cannot hold office or vote on matters pertaining to the AAPA.
_____ SUSTAINING MEMBER $50/yr
Non-practicing PAs or PAs practicing outside of Arkansas. Non-PAs wishing
to join are subject to the approval of the Board of Directors. Cannot hold
office or vote on matters pertaining to the ARAPA.
_____ STUDENT MEMBER $10/yr
Student in a CAHEA or CAAHEP accredited PA program.
_____ PHYSICIAN MEMBER $50/yr
Any Arkansas licensed physician.
Dues are paid annually for the period of 1 October through 30 September.
CONFIDENTIALITY
Would you like to be included in our membership directory?
Yes No (Circle One)
ADDITIONAL INFORMATION
Are you a member of another constituent organization (chapter, specialty org., caucus)?
Yes No (Circle One)
If yes, please identify. ____________________________________________________
COMMITTEE INTERESTS
_____ Membership Committee: Promotes membership in the ARAPA. Contacts new PAs and
welcomes them to Arkansas, explains ARAPA and offers them membership.
_____ Legislative Committee: Monitors legislative activity in Arkansas and determines its
affect on the PA profession.
_____ Nominations/Elections Committee: Charged with coordinating the nomination
platforms and ballots. Tabulating the results and notifying the new officers.
_____ CME Committee: Provides quality continuing education and opportunities for
interaction and social activities.
I certify that the information provided on this application form is true and accurate to the best of
my knowledge.
__________________________________________ ____________________
Signature
Date
Make checks payable to Arkansas Academy of Physician Assistants
Mail check and completed form to:
