First Name  
Last Name  
Degree  
Address  
Address 2  
City  
State  
Zip  
Telephone  
Email  
Phone messages should be directed to:
_____Home ______Work
Postal mail should be directed to:
_____Home ______Work
Employer  
Employer Phone  
Employer Address  
Employer City  
Employer State  
Employer Zip  
Supervising Phycisian  
Supervisor Board Certified?   _____Yes _____No
Web Site    
Affiliations AAPA Member  
NCCPA Certified  
ASPS Member
Membership Type  Fellow $50
Affiliate $50
Physician $100
Associate $100
Student $10
Sustaining $20
Please send to:
Treasurer
Kristen Snyder
3271 John Hancock Dr.
Tallahassee, Fl 32312
850-385-4596
kris10@nettally.com