WAPA Information Update
Please use this form
only
if it is an update to your current membership information. An application to join WAPA can be found
here
.
Full Name:
Date of Birth:
Title:
(PA-S/PA/PA-C/MPAS/PhD)
Medical Specialty:
Home Address:
City:
State:
Zip:
Work Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email Address:
Fax:
PA Program:
Date of Graduation:
Preferred address for WAPA correspondence:
Home
Work
Are you a veteran?
Yes
No
If yes, what branch
Active
Inactive
Reserve
Retired
Would you like the information above to appear in the WAPA Membership Directory?
Yes
No
Yes, but ONLY for the items checked:
Name
Email
Fax
Home Address
Home Phone
Work Phone
Work Address
Med. Specialty
PA Program
Graduation Year
AAPA Member?
Yes
No
AAPA Member #
Are you willing to be a preceptor for a PA student?
Yes
No
Are you interested in serving on a WAPA committee?
Yes
No
Check interests below:
CME
Diversity
Website
Public Education
Membership
Newsletter
Regional Chapter
Student Affairs
Legislative
Elections
Health/Wellness
Reimbursement
INQUIRIES:
Contact Linda Krause at the WAPA Office at 206-956-3624, or call toll free 1-800-552-0612, Ext. 3006 or email
lmk@wsma.org
.
