Membership Application

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PERSONAL INFORMATION
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Check this box if Billing Address and Mailing Address are the same.
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Female

 

EDUCATION
Discipline/Degree:
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Highest Degree Obtained:
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SPECIALTIES / INTERESTS
Select one or more of the following specialties:


























Select one or more of the following interests:























 

MEMBERSHIP CATEGORIES & ELIGIBILITY REQUIREMENT
MD, DO, MD-PhD, PhD, Psych $395
Nursing, PT, OT, SLP, SW $225
Industry, Law, Family $225 
$1500 
$2500 
If you are paying online for a Clinic/Institutional membership, please provide contact information for the person in charge of the Clinic/Institutional membership.
Clinic/Institutional membership forms are available on the ASIA website here. The forms should be completed and submitted to Greg Leasure or faxed: 804-282-0090
$5000 


(mm/dd/yyyy)
$50

 

MEMBER REFERRAL
I was referred by: (if any)

 

PAYMENT INFORMATION
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The deliberations of the Membership Committee and of the Board of Directors of ASIA on matters of membership are strictly privileged and confidential; are not subject to publication or public dissemination whether voluntary, involuntary, or by operation of law; and are not subject to discovery in connection with any court action, administrative proceeding or similar matter.

It is hereby agreed by the applicant that, in consideration of ASIA's treatment of the entire contents of this application, as well as the products or investigation made pursuant thereto, as privileged and confidential material, the applicant specifically authorizes ASIA and its representatives to make whatever inquiries and investigation they deem appropriate to verify the credentials, professional standing, and ethical character of the applicant. Clicking the "Send Application" Button constitutes acceptance of the above agreement.