Membership Application
Personal Information
Name:
Spouse/Significant Other:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Fax:
E-mail:
AAPA #:
KBHA #:
(Required for Fellow Membership)
Program Graduated from:
Year:
Supervising Physician(s)
Name:
Type of Practice:
Address:
City:
State:
Zip:
Name:
Type of Practice:
Address:
City:
State:
Zip:
Committees on which you wish to serve
Membership
Scholarship
Finance
Public Education
CME
Legislative
Professional Wellness
Membership Fee Schedule
Fellow - $90.00
Sustaining - $90.00
Student - $25.00
Physician - $25.00
Federal Employee - $65.00
Associate - $90.00
Affiliate - $40.00
Copyright © 2011 by the Kansas Academy of Physician Assistants.
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