CO Annual Update Form

Thank you for submitting the annual constituent organization update form. Each constituent organization must complete this form at the beginning of the leadership year. Please upload a copy of current bylaws with this form. To remain in good standing, due dates are listed below:

- Leadership year beginning January 1: No later than January 15

- Leadership year beginning July 1: No later than July 15

- Leadership year beginning any other month: No later than the 15th day of same month

To report leadership changes during the year, or for assistance in completing this form, please email coadministrator@aapa.org or call 571-319-4392.

ADMINISTRATIVE INFORMATION

Constituent Organization Name (Please do not use acronym): *

This organization is a *

Mailing Address: *

City: *

State: *

Zip Code: *

Phone Number (Please note that this number will appear on AAPA's web site): *

Fax Number:

Primary Contact Name (Please note that this person’s name will be listed as the contact for the CO on AAPA’s website until another name is submitted. Leaving this position blank will default back to the last submitted contact on file with AAPA):

Name of Executive Director or Paid Administrative Staff if applicable:

Name of Management Company if applicable:

General Email Address for Constituent Organization:

Web site address:

Link to Constituent Organization Facebook page:

Link to Constituent Organization Twitter page:

Link to Constituent Organization LinkedIn page:

Fiscal year begins: *

Leadership Term *

January - December 2024

July 2023 - June 2024

July 2024 - June 2025

Special Interest Group without a defined leadership year

Other (please specify, including months and years) Other (please specify, including months and years)

Membership Term: *

Special Interest Group without defined membership term

January - December

July-June

Anniversary (12 months)

Other (please specify): Other (please specify):

Constituent Organization Membership:

Note: If constituent organization is a special interest group without defined membership categories, please provide total number of SIG supporters.

	Number of Members	Dues Fee by Category
Special Interest Group - Total Supporters	Number of Members	Dues Fee by Category
Fellow	Number of Members	Dues Fee by Category
Graduate PA (Non AAPA Fellow)	Number of Members	Dues Fee by Category
Student	Number of Members	Dues Fee by Category
Physician	Number of Members	Dues Fee by Category
Honorary	Number of Members	Dues Fee by Category
Retired	Number of Members	Dues Fee by Category
Other	Number of Members	Dues Fee by Category
Other	Number of Members	Dues Fee by Category
Total Number of Members	Number of Members	Dues Fee by Category

Name of membership category for PAs who are not AAPA members (i.e., Affiliates, Associates, Sustaining, etc.):

Continuing Medical Education:

Do you have any upcoming CME events scheduled? *

Yes

No

Name of Event *

Dates of Event *

City where event is being held *

State/territory where event is being held *

Venue *

Email for Event Contact *

LEADERSHIP INFORMATION

All Chapter, Specialty Organization and Caucus Officers must be Fellow members of AAPA (President, President-elect, Vice President, Secretary and Treasurer, or Secretary/Treasurer).

Enter leader names in the spaces provided. If position is not required in CO bylaws, enter N/A. If position is required, but unfilled, enter Vacant.

President: *

President-elect *

Past President *

Vice President *

Secretary:

Treasurer:

Secretary/Treasurer:

Student Director or Representative: 🛈

Does Student Director or Representative have board voting privileges?

Yes

No

Directors at Large: 🛈

	Name	Other title, please specify:
1.	Name	Other title, please specify:
2.	Name	Other title, please specify:
3.	Name	Other title, please specify:
4.	Name	Other title, please specify:
5.	Name	Other title, please specify:
6.	Name	Other title, please specify:

Diversity Contact (this position is now required by AAPA policy): *

CME Contact:

Legislative Contact:

Reimbursement Contact:

Name of Constituent Organization Lobbyist, if applicable:

Membership Contact:

HOUSE OF DELEGATES

Chief Delegate: *

Delegates: Note: List your delegates (and extra delegates) below. The number of extra delegates allowed for each delegation is 50% of their apportioned number of seats/votes or 5 extra delegates; whichever is greater.The number of seats apportioned to your organization and the order in which delegates are listed below shall be used to determine who is eligible to vote should the need for an electronic vote occur. Changes can submitted via the delegate change form or by emailing tshoemaker@aapa.org.

	Name
1.	Name
2.	Name
3.	Name
4.	Name
5.	Name
6.	Name
7.	Name
8.	Name
9.	Name
10.	Name
11.	Name
12.	Name
13.	Name
14.	Name
15.	Name
16.	Name
17.	Name
18.	Name
19.	Name
20.	Name
21.	Name

BYLAWS

All Chapters, Specialty Organizations and Caucuses are required to operate under governing bylaws. Please upload a copy of your current bylaws or email to coadministrator@aapa.org.

Informal Special Interest Groups that are not required to operate by governing bylaws, please disregard.

Formalized Special Interest Groups that are governed by bylaws are required to provide them to coadministrator@aapa.org.

Please attach a copy of your current bylaws or email to coadministrator@aapa.org: *

Additional Comments:

Name of Individual Submitting Form: *

Date (MM/DD/YYYY): * +