2012 PPSIG Membership Renewal or New Application

Note: EACH MEMBER (Principal or Associate) MUST COMPLETE A SEPARATE FORM

Notes on Application

Please indicate below whether you are the principal member ($300) for your practice, an associate PT member ($150) from the same practice as a principal member, or a retired member ($50).
If you are paying as an "associate member" you must list the name of your principal member.
If you prefer to fill out a printed application and mail/fax it to us, please download our Membership Registration Form (PDF).

Secure Online Membership Registration/Renewal Form:

Type of Membership:

Principal Member ($300.00)
Retired Member ($50)
Associate Member from same practice ($150.00)

Applicant Information:

APTA Number:

Principal Member Name:

Clinic Name:

Clinic Address:

Clinic City: State: Zip:

Business Phone:

Business Fax:

Email:

Website:

Comments:

I hereby apply for membership, or renewal of my membership, in PPSIG, and certify that I am a member in good standing of the APTA and PTWA.

WEBSITE RELEASE OF INFORMATION

I understand that unless I check an "opt out" option below my member and business information included above will be listed on the PPSIG website, and that this has potential marketing benefits to me.

I agree to have my information included.
"Opt out" Option 1: I do not want any of my information above listed on the PPSIG website.
"Opt out" Option 2: I want the following information excluded from the PPSIG website:

After clicking "Register Now" we will check for any errors on your form and report any we find. If none, you will be directed to PayPal where you can make a secure payment to us through credit card or your bank account.