Membership Application :: PERSONAL INFO ::

Fill-out form with your personal information

Basic Personal Data

First Name:

Last Name:

Middle Initial:

Office Address:

Suite, etc:

Province:

City:

State:

Country:

Zip Code:

Contact Info

Contact Person:

Office Phone:

Home Phone:

Fax Number:

Practice Name:

Title:

Website:

How did you hear about aasp:

Method of Contact:

Email:

Member ($250 per year)

This level of membership is for physicians (MD, DC, DO) whose practice/interest includes the care of patients with spinal disorders.

DEGREE 1:

DEGREE 2:

DEGREE 3:

SPECIALITY

Affiliate Member ($150 per year)

This level of membership is for allied healthcare professionals involved in spinecare and/or spine research. Designate your degree and your specialty below

DEGREE:

SPECIALITY

Candidate Member ($35 per year)

This level of membership is for residents who have an interest in spinecare. Designate your status below.

Status

-- IMPORTANT --

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.

Card Number:

Name on card

Expiry

CVS:

Card Type:

Billing Address:

City:

State:

Country:

Zip Code:

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

I further agree that I will honor and comply with all local, state and federal laws and regulations which apply to me 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. If fraudulent information information is submitted, the application/membership is void.

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/partners assume no responsibility for any of my activities or actions. Membership dues are subject to change over time. If fraudulent information information is submitted, the application/membership is void.

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AGREE DECLINE

Basic Personal Data

Contact Info

Member ($250 per year)

DEGREE 1:

DEGREE 2:

DEGREE 3:

SPECIALITY

Affiliate Member ($150 per year)

DEGREE:

SPECIALITY

Candidate Member ($35 per year)

Status

-- IMPORTANT --

-- WE WILL NOTIFY YOU UPON YOUR ACCEPTANCE --

Your Application has been submitted to The AASP

Membership Acceptance will be sent via email

Academy Contact Information - Phone: (847) 697-4660 - Email: [email protected]