Home     Privacy Statement     Download Printable Application

An Organization of Healthcare Professionals Dedicated to Excellence in Spinecare

Membership Application

First Name:
Last Name:
Middle Initial:
Office Addr:
Suite, etc:
Zip Code:

Contact Person:
Office Phone:
Home Phone:
Fax Number:
Practice Name:
Web Site http://
How Did You hear about The AASP:
Method of Contact:

Please check the appropriate membership category

Prices Good thru June 30th, 2007

Member ( $125 per membership year ) Neurosurgeon Chiropractic Physician

Associate Member ( $125 per membership year ) M.D. D.O.   (designate your specialty below)
Orthopedic Surgeon Radiologist Rheumatologist Physiatrist Osteopath
Pain Management (  Other    )

Candidate Member ( $35 per membership year )
Student Resident Fellow

Membership will automatically renew one calender year from the date of membership acceptance unless the AASP is specifically notified in writing by the member 30 days prior to their renewal date. Please address all correspondence to the AASP Office of Member Services. Membership dues are subject to change with prior notification.

Card Number:
Name on Card:
Expiration Date: /
Card Type:
Billing Address:

I hereby make voluntary application to the American Academy of Spine Physicians (AASP). I understand and agree that in making application to, and/or being accepted as a member of the AASP, that I am a licensed healthcare professional and that my professional practice as such includes the evaluation and care of patients with spinal disorders.

I further agree that I will honor and comply with all local, state and federal laws and regulations which apply to me as a person and professional, and that I will conduct myself in a manner consistent with the highest level of professional ethics and in accordance with the ethical standards of the AASP as outlined in the AASP Documentation Library.

I affirm that the information I have provided to the AASP is true and accurate. I agree to function within the limits of my training, competence and professional license or certificate. I further understand and agree that the AASP and its affiliates assume no responsibility for any of my activities or actions.