APPPA   MEMBERSHIP APPLICATION

DATE________________


MEMBER'S FULL NAME __________________________________________________NICKNAME__________

HOME ADDRESS _______________________________________
_______________________________________

HOME NUMBER________________ CELLPHONE_______________
Can your cell phone receive text messages? YES_____ NO____

How would you like to be contacted for APPPA activities ?
Email _________ Phone ______________ Snail Mail ______

E-MAIL ADDRESS____________________________

MEDICAL SCHOOL______________________

YEAR GRADUATED_____ SPECIALTY________________________

OFFICE ADDRESS________________________________________

OFFICE TELEPHONE NUMBER ______________ FAX________________

AUXILIARY MEMBER'S NAME___________ NICKNAME_____________

WHAT ACTIVITIES WOULD YOU BE INTERESTED IN ? _____________________________________________________________________

HOBBIES _____________________________________________________

SUGGESTIONS AND COMMENTS ( What activities would you like the APPPA to be involved in ?)

_____________________________________________________________________________________________________________________________________________________________________________________________________________CHILDREN _______________________________________________________________________________________________________________________________________________

CHILDREN AND AGES ___________________________________________________

_______________________________________________________________________

THE INFORMATION ABOVE WILL BE USED EXCLUSIVELY FOR THE APPPA
ORGANIZATION. IT WILL NOT BE SOLD OR USED FOR SOLICITATION. 



Signature

(  Copy and Paste to WORD and attach to Email, or print the page and submit at one of our future meetings )  Either way,  JOIN US !  We would like to meet ALL  NEW and ( not so new ) Filipino doctors practicing in AZ.