Midwest Chapter - AAOP - Membership Application

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Membership Application - Annual Renewal Statement

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Name:		Company:
Address:		Phone:
City:		State/Zip:
E-Mail:		Fax:
Credentials:
Certificate type and number:

Membership Fees: (check one)
Active Member (active academy Member)	$35.00
Associate (non-active Academy Member)	$45.00
Affiliate (Cped, fitter etc.)	$45.00
Allied Health Professional	$45.00

This is to certify that I am a ABC (American Board for Certification) certified practitioner, and a member in good standing of the National Academy of Orthotists and Prosthetists.

(enter information only if you are a member of ABC)

Name:

Date(MM/DD/YYYY):

Please click here if you would like to receive:
		Up-to-date industry information
		View New member and New vendor Information
		Notification of upcoming events

Total Membership Fees:

Notice: You will be redirected to PayPal.com for payment processing. You may use a credit card by scrolling down on the PayPal site to the “Don’t have a PayPal Account” Section of the PayPal Website.