Gastroenterology Physician Assistants

Name

Title

Home Address

City

State

Zip Code

Home Phone

Company Name

Work Address

City

State

Zip Code

Work Phone:

Preferred E-mail Address:

AAPA Member

AAPA Member ID

NCCPA Certified

NCCPA Certificate #

NCCPA Exp. Date

My sub-specialty/areas of expertise:

My work setting is:

Supervising Physician

Please use this address for my membership mailings:

Home

Work

May we share your contact information for CME, employment, and product information purposes?

May we list your information in the GIPA membership directory?

Please provide me with a complimentary membership to the American Association for the study of Liver Disease. (Submit proof of membership dues payment for reimbursement to GIPA at 950 N. Washington St., Alexandria, VA 22314. To join, visit www.aasld.org)

Membership Categories

Fellow Membership - Dues $30

Physician Assistants who currently practice in the field of gastroenterology.

Sustaining Membership - $30

PAs certified by the NCCPA, who have chosen not to practice in Gastroenterology and Hepatology, but who still wish to support GIPA

Physician Membership - $30

U.S. licensed physicians who wish to associate with and support the organization

Affiliate Membership - $30

Persons ineligible for the above categories and wish to associate with the organization. Their memberships must be approved by the Board of Directors

Student Membership - Dues $10

Physician Assistant students who are currently enrolled in an ARC-approved PA program. Students are not eligible for membership to the Crohn’s & Colitis Foundation.

Additional Areas of Support

I would like to serve GIPA in the following capacities:

Membership

CME Planning

Newsletter

Leadership

Speaker/Topic

Payment Options

I would like to make an additional donation to support the efforts of GIPA.

$25

$50

$100

$250

Total Payment

Credit Card

Visa

Master Card

American Express

Check Enclosed

Name on card

Card Number

Expiration Date

If paying by check, please make your check payable to GIPA and mail to 950 North Washington Street, Alexandria, VA 22314-1552

To fax this membership application with credit card information, please fax to 703/684-1924

GIPA Membership Application TAX#27-0001314 DUN#827651006