Constituent Organization Officers Update Form
Every constituent organization must complete this form twice a year.
Forms are due to AAPA in January and June of each year.
Organization Information
Organization's Name
Permanent Mailing Address
Street or P.O. Box
City
State
1) Alabama
2) Alaska
3) Arizona
4) Arkansas
5) California
6) Colorado
7) Connecticut
8) Delaware
9) District of Columbia
10) Florida
11) Georgia
12) Hawaii
13) Idaho
14) Illinois
15) Indiana
16) Iowa
17) Kansas
18) Kentucky
19) Louisiana
20) Maine
21) Maryland
22) Massachusetts
23) Michigan
24) Minnesota
25) Mississippi
26) Missouri
27) Montana
28) Nebraska
29) Nevada
30) New Hampshire
31) New Jersey
32) New Mexico
33) New York
34) North Carolina
35) North Dakota
36) Ohio
37) Oklahoma
38) Oregon
39) Pennsylvania
40) Rhode Island
41) South Carolina
42) South Dakota
43) Tennessee
44) Texas
45) Utah
46) Vermont
47) Virginia
48) Washington
49) West Virginia
50) Wisconsin
51) Wyoming
Zip
Phone Number
Fax Number
Web site address
E-mail address
Paid Executive Staff
Or Main contact
Organization Officers/Leaders
Please fill out officer information as accurately as possible. If your organization does not have a person for a position please list as vacant.
If you have any questions regarding filling out this form you can contact Sue Curtis at
scurtis@aapa.org
.
From
Until
Term of Office
President
President Elect
Past President
Vice President
Secretary
Treasurer
CME contact
Legislative contact
Newsletter contact
Membership contact
Minority Affairs/Diversity contact
Public Education contact
Reimbursement contact
Nominating/Election contact
Professional Wellness contact
Web site contact
Historian
Student Representative/s (PA-S)
Student Affairs Contact/s (PA-C)
Director/s at large or Regional Representative/s
Elected Board of Directors
Please list the names of all officially elected board of directors.
Membership Information
Dates of the membership dues year From
Anniversary date
January
February
March
April
May
June
July
August
September
October
November
December
To
Anniversary date
January
February
March
April
May
June
July
August
September
October
November
December
Number of members and dues fees by membership category:
Fellow
Affiliate
Student
Associate
Sustaining
Physician
Other
Number
Dues
We accept: Visa
Yes
No
or Mastercard
Yes
No
for dues payment.
Our organization's constitution and bylaws have been updated in the past year.
Yes
No
Please mail copies of updated bylaws to Sue Curtis at AAPA, 950 North Washington Street Alexandria, VA 22314-1552 or fax, to 703/684-1924.
Upcoming CME Information
List your upcoming CME events.
City
State
Dates
Number of Attendees
Event 1
Event 2
Event 3
Event 4
Additional Comments
Name of officer submitting form
House of Delegates Information
Please submit the House of Delegates Designation Form with your HOD delegates and alternates to Tom Shoemaker at AAPA, 950 North Washington Street, Alexandria, VA 22314-1552. For questions or copies of the form, contact Tom at
tshoemaker@aapa.org
.