ASPSA Membership Application

Membership Application

To join ASPSA, you must first send in a completed application with your membership dues.

To join ASPSA you can either fill out this form and submit, you can then use the “BUY NOW” button below to be redirected to a secure site where you can pay by credit card. Or, if you’d rather send a check, please print out this page, complete the application and mail it in with your payment.

A membership in ASPSA belongs to the practice; however, please fill in the name of your office administrator or manager who will be representing your practice. This membership is transferable in the event of staffing changes.

Membership Application

Before submitting this form, please print out this page and mail it to the PSAA address below.

MANAGER'S NAME*
Prefix First Last Suffix
PRACTICE OR PHYSICIAN EMPLOYER'S NAME*
Prefix First Last Suffix
MAILING ADDRESS*
Street Address City ZIP Code
State / Geographical Division
OFFICE TELEPHONE*
OFFICE FAX
HOME TELEPHONE
E-MAIL ADDRESS*
Website
REFERRED BY
Please Select one:
- MEMBERSHIP RENEWAL
- NEW MEMBERSHIP
* Required. Please use the BUY NOW button below to purchase a membership plan.
Please answer the math question:

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Membership Dues:
Annual Membership Dues – $150

MAIL APPLICATION AND CHECK TO:

ASPSA
6324 Fairview Ave N
Crystal, MN 55428

Membership Application

Membership Application

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