ASP NEW SOCIETAL MEMBER APPLICATION FY 2019

(July 1, 2018–June 30, 2019)

Societal membership in ASP is open to all internal medicine specialty societies. Each society is represented by its executive director and any additional staff member(s) or societal leader(s). Annual membership dues are $3,620.

Society Contact Information

Email address of person completing this form *

Organization Name *

Specialty *

Address *

Address

City *

State/Province *

Zip Code *

Country *

Telephone *

Fax

Organizational Email *

Organization Website

Executive Director Information

First Name *

Last Name *

Suffix

Title *

Telephone *

Fax

Email *

Payment Information

If paying by check, please make payable to AAIM and mail to:

AAIM
PO Box 222181
Chantilly, VA 20153-2181

(AAIM's Tax ID number is 27-3063631)

If paying by credit card, please call AAIM Member Services at (703) 341-4540.

Additional Societal Staff Contacts

Public Policy Contact

First Name

Last Name

Suffix

Title

Telephone

Fax

Additional Staff or Societal Leader

First Name

Last Name

Suffix

Title

Telephone

Fax

Additional Staff or Societal Leader

First Name

Last Name

Suffix

Title

Telephone

Fax

Additional Staff or Societal Leader

First Name

Last Name

Suffix

Title

Telephone

Fax