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Chapter Membership Application/Information Form
Alabama
Chapter
19 S. Jackson St.
Montgomery, AL
36104
(334) 954-2543
Fax: (334) 269-5200
Tab through the form and complete highlighted items; boxes can be checked by using the spacebar. Please print & sign below.
Name
Preferred Mailing Address
City
Is this your:
State
Work address
County of Home
Zip
Home address
County of Work
Work Phone
Home Phone
Email Address
FA
X
Practice Name
CATEGORY OF CHAPTER MEMBERSHIP (Membership in AAP qualifies you for AL Chapter Membership)
Fellow (Physician who is FAAP-designated)
Specialty Fellow (AAP member certified by a board other than a pediatric board)
Senior member (fully retired)
Associate Member (Pediatric Dentists)
Candidate Member (board-eligible AAP member not yet certified in pediatrics)
Post-Residency Training Member (AAP must have letter from fellowship program dir.)
Resident Member (Pediatric resident who belongs to the AAP)
Medical Student
Honorary Fellow Fellow
National Affiliate Member (Physician Assistants & Nurse Practitioners)
Dues:
Dues:
Dues:
Dues:
Dues:
Dues:
Dues:
Dues:
Dues:
$165
$165
$0
$165
$83
$0
$0
$0
$100
I am not a member of the AAP (national) but wish to inquire about AAP membership as well.
Specialty
Board-Certified?
Primary Work
Time Devoted to
Pediatrics
_________
Yes
No If yes, Specialty/Field
Private practice
Academic
Administration/Management
Full-time
Part-time
Date
__
Hospital
Government
Public Health
________
_
_________
Other (please explain)
Medical School (or dental school)
Internship
Residency
Fellowship
Hospital Affiliation
Medical Society Memberships
Applicant Signature
Date