.
Membership
Annual Meetings
Employment Opportunities
Certification
Directory
Online CME
Resource Library
Testimonials
Board and Staff
News
Related Meetings
Links


AMERICAN SOCIETY OF ORTHOPAEDIC PHYSICIAN'S ASSISTANTS
8365 Keystone Crossing
Suite 107
Indianapolis, IN 46240
(800) 280-2390
(317) 205-9481 Fax
asopa@hp-assoc.com

 Last modified on 3/1/10

ASOPA Membership Application

* Required Fields

* First Name

* Last Name

* Credentials

* Address

* City

* State

* Zip

* Email Address

* Home Phone

* Would you prefer to receive the ASOPA Newsletter by: Mail Email

Employment Information

* Employer

* Phone

* Address

* City

* State

* Zip

* Employed from to Position:

* Type of Membership
Fellow Membership is reserved for those that have passed the certification exam given by the National Board of Certification of Orthopaedic Physician's Assistants (NBOCPA).

Fellow Membership
$200

Affiliate Membership
$200

* Have you passed the National Board for Certification of Orthopaedic Physician's Assistants Exam? Yes No

If yes, the date and number that appear on certificate:

Number

Effective Date

Expires

* Are you a graduate of an O.P.A Program? Yes No

* Are you a graduate of a Primary Care Program ? Yes No

If yes, are you certified ? Yes No

* Have you been trained on the job ? Yes No

If yes, by whom? Dr.

Address

City

State

Zip

* Did you receive training from the Armed Forces? Yes No

If yes, when: Where:

Branch of Armed Forces: Serial #:

Educational Information - Fill in information for highest level completed

Type of School

Name

Major

Last Year

Degree

Please indicate highest level completed

High School 1 2 3 4

College 1 2 3 4

Post Graduate 1 2 3 4

Other 1 2 3 4

Payment

* Visa/Mastercard Number

* Expiration Date

* Cardholder Name