Name/Clinic
First Name:
Middle Name:
Last Name:
Email:
Clinic:
Web Site:
Contact Information

Work Address: City: State: IAALAKAZARCACOCTDCDEFLGAHIIAIDILINKSKYLAMEMDMAMIMNMSMOMTNENHNJNMNYNVNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Work Phone: Fax:	Home Address: City: County: State: IAALAKAZARCACOCTDCDEFLGAHIIAIDILINKSKYLAMEMDMAMIMNMSMOMTNENHNJNMNYNVNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Home Phone: Mobile Phone:
Mailing Address
Make my primary mailing address my work address Make my primary mailing address my home address

Tell Us About Yourself
1. What is your professional designation (check one):
PA     PA-C     ARNP     MD     DO     Other

2. I am a licensed PA in Iowa: No     Yes: (number)

3. My employer pays for my membership in IPAS: No     Yes

4. I am a member of AAPA: No     Yes: (number)

5a. If you are currently a PA Student:
1st Year     2nd Year       Program

5b. Otherwise:
Name of PA program you graduated from:

6. Check here if you prefer to not list your information in the IPAS Membership Directory.

7. To save postage and printing costs, we will email the quarterly newsletter to IPAS members.
Check here if you prefer to continue receiving a mailed, hard copy of the newsletter.

Committee Interest
Please mark any committees on which you would like to serve. Check all applicable.

Board of Directors Student Representative to the Board Communications (Newsletter, website) Membership Legislative and Health Policy

Conferences AAPA HOD Delegate Finance Public Education Awards

Membership Level

Fellow ($125)Affiliate ($150)Associate ($40)Retiree ($40)Associate NP ($125)Supporter ($125)Student ($25)Graduate ($50)

The following levels of membership are available:

• Fellow (PA who is a member of AAPA and works in Iowa) $125
• Affiliate (PA who is not an AAPA member and works in Iowa) $150
• Associate (Not working as a PA, or lives and works outside Iowa) $40
• Retiree (Retired PA who wants to stay current with the profession) $40
• Associate Nurse Practitioner (Advanced Registered NP) $125
• Supporter (Non-PA who receives newsletter and other information) $125
• Student (Currently enrolled in a CAAHEP-approved program) $25
• Graduate (Available for students immediately after graduation through the end of their graduate year) $50

Donations to the IPAS Foundation
Membership dues to IPAS are not tax deductible for income tax purposes. However, dues may be deductible as a necessary business expense subject to restrictions imposed as a result of IPAS lobbying activities. IPAS estimates the nondeductible portion of dues to be 18%. Contributions or gifts to the IPAS Foundation for scholarship awards are 100% deductible.

**A donation to the IPAS Foundation helps support the annual scholarships IPAS awards to student PAs studying in Iowa. Your gift to the Foundation is tax deductible as a charitable donation.

Membership Payment Options
Since you can pay for many members in one payment, you have the option to either send a check or charge the payment to MasterCard or Visa. If your payment is for someone other than the person registered on this application, please make a note of that in the box above. Your credit card will only be charged for the level of membership you selected if there are no additional instructions.

Pay by check. Please make checks payable to 'IPAS' and send to the following address: Iowa PA Society 525 SW 5th Street Suite A Des Moines, IA 50309		Pay by credit card. Please enter your credit card information as it appears on your card. Note that this is a secure connection and the transmission of your credit card information is safe. Name as it appears on the card: Type of card: Choose:MasterCardVisa Card number: CID/CVV: Expiration (month/year): 123456789101112 2008200920102011201220132014201520162017