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Applicant Information

Name of Applicant

Type of Membership

Principal Member ($150)
Associate Member from same practice ($150)
Retired Member ($50)

APTA Number

Principal Member Name

Clinic Name

Clinic Address

Clinic City

Clinic State

Clinic Zip

Business Phone

Business Fax

Website

Comments

I hereby apply for membership, or renewal of my membership, in PPSIG, and certify that I am a member in good standing of the APTA and PTWA.

Website Release of Information

I understand that unless I check an "opt out" option below my member and business information included above will be listed on the PPSIG website, and that this has potential marketing benefits to me.

Website Release Options

Exclude this Information from the PPSIG Website

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