GAPA 2017 Online Membership Form


Please complete and submit the membership form below. If you prefer, you may complete the form, print it, and then fax/mail form to send it to GAPA. Note that items marked with an "*" are required fields. Items marked with an "* *" are required for all students. Click here to view GAPA´s membership brochure.

For renewals, please review your information contained in the Membership Directory, and correct it as appropriate. Click here and then provide your username and password to access the Membership Directory.

Date:
 
General Information
GAPA Membership ID #:
(If known)
*First Name: A value is required.  Invalid entry.
Middle Initial: Invalid entry.
*Last Name: A value is required.  Invalid entry.
Suffix (ex: Jr., Sr.): Invalid entry.
Credentials (ex: PA-C, MPAS): Invalid entry.
*Email Address: A value is required.  Invalid entry.
*Address Line 1: A value is required.
Address Line 2:
*City: A value is required.
*State: Please select a state.
*Zip Code A value is required.  Invalid entry. - Invalid entry. The entered value is less than the minimum required.  The entered value is greater than the maximum allowed.
County:
*Home Phone Number: A value is required.  Invalid format.  Invalid entry.
Work Phone Number: Invalid entry.
Cell Phone Number: Invalid entry.
Fax Number: Invalid entry.
*Type/Specialty of Practice in which you work: A value is required.  Invalid entry.
License Number:
Supervising Physician:
* *PA Program
* *Graduation Year 4 digit year value only.  The entered year is less than the minimum allowed.  The entered year is greater than the maximum allowed.
*Membership Type:  New Member     Renewal Please make a selection.
*Please indicate if your employer pays your GAPA membership dues:  Yes     No Please make a selection.

Membership Categories:
*Membership Categories:
(Select One)
Membership Descriptions
FELLOW
1 Year
2 Year
$175/yr -or- $325/2yr - FELLOW members include graduates of PA Programs approved by the Board of Directors and/or persons certified by the NCCPA, who are Fellow members of the AAPA and are eligible to vote and to hold office.
ESTEEMED MEMBER
1 Year
2 Years
$150/yr -or- $275/2yr - LOYALTY DISCOUNT - Those that have been a GAPA member 5 or more consecutive years.
NEW GRADUATE MEMBER
1 Year
2 Years
$125/yr -or- $225/2yr - NEW GRADUATE - For those who have graduated from an accredited PA program. Only good for the 1st two years out of school.
ASSOCIATE
1 Year
2 Years
$175/yr -or- $325/2yr - (Non-AAPA Member PAs) ASSOCIATE members include PAs certified by the State of Georgia and other PAs approved by the Board of Directors and may vote on non-AAPA matters and hold office as directors-at-large.
MILITARY/ RETIRED
1 Year
2 Years

$160/yr -or- $275/2yr - Members who are Retired or with the Military.

AFFILIATE $50/yr - Affiliate members shall include other persons not eligible for Fellow or Associate membership who desire to affiliate with the Association.
STUDENT Waived - (for entire student period + 6 months) - STUDENT members are persons enrolled in Board-approved programs training PAs and may not vote or hold office except for the student member(s) elected by their peers for positions on the Board of Directors.
GROUP RATE - A Group rate is available for practices that hire multiple PA's. If you have 4 or more PA's in your practice, please call the GAPA Office for further details on the discount

Miscellaneous
Check if you would like to be added to GAPA´s mentor list for precepting pre-PA and PA students
Please consider the following options:
Student Scholarship Fund Donation $ Invalid entry.   
PAs For Healthcare Access (Political Action Committee) –
   $25.00 (suggested minimum)
$ Invalid entry.   

Grand Total $

Payment Information
* Please complete all fields in this section unless you are a student
registering with a $0 balance.


Visa  MasterCard  Discover  American Express 
Please make a selection.


Credit Card #: A value is required.  Invalid entry.

First Name as it appears on Credit Card: A value is required.

Last Name as it appears on Credit Card: A value is required.

Expiration Date (MMYY format): A value is required.  Invalid entry.

Card Verification Code: A value is required.  Invalid format.      CVN    What is this?

Billing Zip Code: A value is required.  Invalid entry.

If nothing seems to happen after you click on the 'Submit Membership Form' button below, scroll up and look for any red background fields, or red error message text. This indicates field values that need to be corrected.

GAPA's membership year is from January 1 - December 31 of each year. For someone who submits dues after September 1, they will be considered a member for the balance of the current as well as the entire subsequent year. Membership investments in GAPA are not tax deductible as charitable contributions but a portion is deductible as a business expense. Since the GAPA engages in lobbying, under Federal law, 57% of annual dues payments are non-deductible.



  



Stay Connected to GAPA! GAPA Goes Green

GAPA GREENIn an effort to lower our environmental impact and preserve our natural resources, GAPA has elected to Go Green! Please look for our Green logo to learn more about GAPA's Green Initiatives.