ConnAPA

ConnAPA Membership

Membership Form

Fill out the form below completely and hit the "Submit" button to move on to our online payment gateway.

Affilate/ Fellow/ Associate Membership dues are $125/year.
Retired or Disabled PAs dues are $25/year subject to approval of the Board of Directors.

Membership Type	Affiliate
Voluntary Donation to CT PAF Scholarships (Suggested Amount-$25)

Name (include Credentials)
Home Address
City
State
Zip
Home Phone
Home Fax
Home E-mail
Cell Phone
Employer Name
Employer Address
Employer City
Employer State
Employer Zip
Employer Phone
Employer Fax
Employer Email
ConnAPA member who referred you (if applicable)

Professional Information
Please be sure to include your CT license and AAPA membership numbers

PA Program
Month/Year of Graduation
CT License #
NCCPA Cert:	YesNo
AAPA Member	YesNo
AAPA Number
Supervising Physician's Name
Supervising Physician's Address (if different from above)
Supervising Physician's City
Supervising Physician's State
Supervising Physician's Zip

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Specialty (pick one)

	Anesthesiology
	Cardiology
	Dermatology
	Emerg Med/ Urgent Care
	Family Practice
	Geriatrics
	Internal Med/ Primary Care
	Neonatal/ NICU
	Nephrology
	Neurology
	Obstetrics/ Gynecology
	Occupational Med
	Oncology
	Opthamology
	Ortho/ Sports Med
	Otolaryngology
	Pediatrics
	Pulmonary
	Physical Med/ Rehab
	Psych/ Substance Abuse
	Radiology
	Surgery – General
	Neurosurgery
	Plastics/ Reconst. Surgery
	Cardiovascular Surgery
	Other

Check all volunteer opportunities in which you'd like to participate

	Membership
	Newsletter
	Legislation
	CME Programs
	Charter Oak Conference
	PR/ Public Education
	Other
	I am willing to have PA program applicants shadow me.

Mailing Lists
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Please help us in our efforts to reach out to your colleagues.
How did you hear about joining ConnAPA?

	Website
	Newsletter
	ConnAPA mailing
	Charter Oak Conference
	PR/ Public Education Effort
	Other