Applicant Information:

First Name: Middle Name: Last Name:

Name wanted on badge:

Address:

City: State: Postal Code:

Phone #: --

Employement Information:

Podiatrist name APMA# (Required):

Office Name:

Address:

City: State: Zip Code:

Phone #: -- Fax#:--

Employed: Years, Months

Email Address:

How did you hear about us:

Type Text here

APPLICANT MUST BE EMPLOYED BY A DOCTOR WHO IS A MEMBER IN GOOD STANDING OF THE AMERICAN PODIATRIC MEDICAL ASSOCIATION.

Application fee is $90.00, plus an additional $5.00 online fee processing charge.This covers the initial cost of society pin, name badge, certificate and current year dues. For assistants joining in August or after, the initial dues will cover the remainder of the year and the following year.

Click the Submit link to submit your application. You will need to then follow the instructions on the next page to process your application fees.