Active Program Member (dues $375)	______
Provisional Program Member (dues $375)	______
Inactive Program Member (dues $200)	______
Affiliate Member (dues $50)	______
Individual Member (dues $50)	______

Program Name:

_______________________________________________________________

Address:_____________________________________________________________

City:__________________________________ State:____________ Zip:__________

Phone:________________________________ Fax:___________________________

Program E-mail address:________________________________________________

Program Director:

_________________________________________________________________

Program Director Phone:________________ Fax:______________

Program Director E-mail address:___________________________

Other Program contact:_____________________________________

___________________________________________________________

Program Specialty:

_________________________________________________________________

Length of Program (Months): _________________________

Number of PA's in Each Class: _________________________

New Provisional Program Members:

(1) A two-paragraph general description and history of the program.
(2) Curriculum outline - include goals and objectives for didactic and clinical components. (3) University and Institutional Affiliations
(4) Admissions process and timetable. Include entry requirements, selection criteria, whether or not an interview is required and program starting date.
(5) Credentials Awarded (i.e. certificate, degree, credit toward degree)
(6) Financial Information including:

Fees/tuition or salary/stipend
Benefits (medical/dental/life insurance/vacation, etc.)
Financial aid, including veterans benefits, if applicable
Housing
Expenses (books, equipment, etc.)

New Active Program Members:

Application should be submitted along with a program brochure, if not already on file, and the following information:

(1) Date of graduation of first class
(2) Number of graduates of first class

Inactive Program Members:

Application should be submitted along with the following information:

(1) Date of temporary suspension of program and anticipated duration of suspension
(2) Reason for suspension of program

Submit to:

Jennifer Jarmin
APPAP, Inc.
300 North Washington St, Suite 505
Alexandria, VA 22314
703-548-5538, ext. 2
703-548-5539 (fax)
appap@appap.org

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