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PHYSICIAN ASSISTANTS IN RESEARCH (PAR)
MEMBERSHIP APPLICATION
NAME: ________________________________________
TITLE: _____________________________
HOME or WORK ADDRESS:
____________________________________________________________________
CONTACT INFO:
H:___________________
W:___________________
FAX:_________________
EMAIL:_____________________________
MEMBERSHIP CATEGORIES: Check one of the following:
___ $50.00 Professional Member—Healthcare professional.
___ $15.00 Student Member
_______________________________________
School Name
Please mail completed applications along with a check (payable to Physician Assistants in Research) for the appropriate amount to:
Physician Assistants in Research
Christen Kutz
1616 Millard Street
Bethlehem, PA 18017
Thank you for your interest in PAR and we look forward to future correspondence.
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