Membership application

NEW MEMBER/PATRON APPLICATION The American Association of Physicians of Indian Origin Sleep(AAPIOS) extends a one time opportunity to join the organization at a reduced annual membership fee of $50.00 per person. Please fill in the application and fax/mail it to AAPIOS Office along with the payment. Membership is only open to physicians and other health care professionals of Indian Origin practicing sleep medicine.

PROSPECTIVE MEMBER PERSONAL INFORMATION

Last Name: __________ First Name: __________ Middle Initial: __________ Degree: □ MD □ DO Other degrees: (RPSGT, RRT, MBBS, BDS, MBA, PhD etc):

Male ____ Female ____

Private Practice ___ Academics ___ Industry ___ Other(specify) __________

Primary Specialty: __________ Secondary Specialty: __________

Current address: City: ____________________ State: __________ ZIP Code: __________

Phone: __________________ Fax: ____________________ Email: ____________________ Medical/Dental School: ____________________ Year of Graduation: __________ Residency Completion Year: ____ Fellowship Completion Year: ___ NOMINATED BY (When applicable) Last Name: __________ First Name: __________ Middle Initial: ___ AAPIOS Membership Number:(If know)

Current address: ________________________________________ City: ____________________ State: __________ ZIP Code: __________ Phone: ____________________ Fax: ____________________ Email: ____________________ Medical/Dental School: ____________________ Private Practice __________ Academics ___ Retired ____ Other(specify) __________

Please make a check payable to the American Association of Physicians of Indian Origin Sleep and mail it along with the filled application form to the address below. _____________________________________________________________

AMERICAN ASSOCIATION OF PHYSICIANS OF INDIAN ORIGIN – SLEEP (AAPIOS) C/O GAUTAM SAMADDER MD, 99 N BRICE RD SUITE 300, COLUMBUS, OH 43213 www.aapios.org