Application of Membership

Please complete the following form to apply for membership into PAD. Do not send payment for membership dues with this application. You will be billed upon enrollment as a member and dues are payable within 60 days after billing. Applications are acted upon by the Membership Committee of the Academy. Applicants will be notified of their application status within 30 days following the Committee’s decision.

Name:   *  
 
Office Address:   *   Home Address:
Office Phone:   *     Home Phone:
 
Fax: Preferred Address:
Email:   *     Preferred Communication:
Birth Date:   *     Gender:
 
Medical School Graduation Year:   *     Degree Received:   *  
Residency Institution:   *     Residency Completion Date:
Fellowship:   Fellowship Completion Date:
Primary Specialty:   *     Board Eligible:   *  
Plan to take Board Examination in:  
Certification Date:   Practice Start Date:
State Licensure(s):   *     State Licensure Year(s):   *  
 
Membership Classification:
 
Sponsor Name: