New Membership Online Application

ASPMA New Member Online Application

Name *

Podiatrist APMA# *

Podiatrist Name: *

Office *

Address *

City *

State *

Zip *

Phone *

Cell Phone *

FAX *

Years employed *

Months Employed *

Duties Performed *

Clinical

Administrative

Both

Radiology

Home Address

City

State

Zip

Email Address *

How did you hear about Aspma *

Checkboxes *

I agree

The ASPMA reserves the right to revoke and/or refuse membership and certification to anyone not complying with the terms of ethics and code of conduct set forth by the ASPMA and APMA. The ASPMA also reserves the right to reinstate such statuses deemed appropriate by the Board of Directors.

Payment

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New Membership Application Assistant

$125.00

Category: Membership