ALLIED HEALTH MEMBERSHIP APPLICATION
Application Must Be Typed or Printed Clearly
Demographic & Professional Information
Name:_________________________________________ _________________________________ _________________
Last (Family Name)
First Name
Middle Name
Designation: CRC
PharmD
PhD
LPN
Medical Administrator
Medical Assist.
MS
NP
Office Manager
RN
Other:______________________________________________________
Date of Birth________ /________ /19__________ MMDD
Ethnicity:
African American
Asian
Gender:
Male
PA-C
Female
YY
Caucasian
Hispanic
Certification:_______________________________________ Native American
License Number:_______________________________
National Provider Identifier (NPI):______________________________________________________________________
Phone: _______________________________ Email:___________________________________________________
Address Information
Preferred mailing address:
Home
Office
Preferred billing address:
Home
Office
Office Name:________________________________________________________________________________________
Office Address:_______________________________________________________________________________
City:____________________________ State:________ Zip:_______________ Country:______________
Home Address:______________________________________________________________________________________
City:____________________________ Education Information
State:________ Zip:_______________ Country:______________
(Please include the country if outside the US)
Undergraduate School Name:____________________________________________________________________________
Area of Study:________________________________ Degree:______________ Start Year:_________ End Year:_________
Graduate School Name:________________________________________________________________________________
Area of Study:________________________________ Degree:______________ Start Year:_________ End Year:_________
Postgraduate School Name:_____________________________________________________________________________
Area of Study:________________________________ Degree:______________ Start Year:_________ End Year:_________
Practice Information
How much of your time is spent with allergic patients?
All Most (>33%) Some (>10%) Occasional None
How much of your time is spent in research/teaching?
All Most (>33%) Some (>10%) Occasional None
Disclosures
Have you ever been the subject of any disciplinary action by a State or Local Medical Society, or by a Medical Licensing Body? Yes No
Have you ever had your hospital privileges or license suspended or revoked? Yes No
If you answered yes to either of the above, please provide an explanation in an accompanying letter to the AAAAI.
Additional Application Information
APPLICATION FEE: A $25 application fee is required for individuals applying for allied health membership; however, the
fee does not apply to the total amount of dues owed upon approval of membership.
LETTER OF INTENT: All applications must be accompanied by a letter of intent from the applicant. This letter should be
signed and dated and should include a statement describing your work within the specialty and your interest in AAAAI.
CV/RESUME: All applicants must include a copy of their current CV/resume with their application containing, at a
minimum, the following information:
• A complete educational history
• Allergy/immunology or other relevant professional society memberships
• AAAAI or other allergy/immunology meetings attended in the last 3 years
• Any current teaching responsibilities including CME courses taught, conferences given, or evidence of providing
continuing education in topics of allergy/ immunology
• Current list of publications
SPONSORS: You are responsible for requesting recommendations from two (2) sponsors. Please note that these sponsors
must be one (1) current Fellow of the AAAAI and one (1) current member of the AAAAI.
Note: incomplete applications will only remain on file for one (1) year. After that time, all application materials will be discarded.
From the Bylaws
Persons engaged in the field of allergy/immunology or a related field, in patient care, in a technical or administrative capacity, or who work in research laboratories are eligible for membership as an allied health member. Examples include licensed
practical nurses (L.P.N.s), registered nurses (R.N.s), physician’s assistants (P.A.s), allergy technicians, pharmaceutical employees, technologists or research associates. Allied health members shall not be eligible to vote, propose motions, serve on
the Board of Directors or hold office.
Membership Information
Allied Health Member Dues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00/year
Some of the valuable benefits of allied health membership include:
• Annual Meeting early registration and exclusive discounts
• Access to a broad range of awards and grants
• Full access to the “Members Only” section of the AAAAI website
• Practice management resources and guidance; including coding assistance
• Networking opportunities with allergy/immunology professionals throughout the world
• Ability to participate in Interest Sections, assemblies and committees
• Discounted subscriptions to The Journal of Allergy and Clinical Immunology (JACI) and The JACI: In Practice
Application Fee Payment
A $25 check, payable to AAAAI, is enclosed OR Charge $25 to my:
AMEX
Discover
MasterCard
VISA
Card NumberExpiration Date
Cardholder Name:Cardholder Signature
Congratulations on taking the first step to AAAAI allied health membership!
Return this form with payment by mail, fax or email (PDF) to:
AAAAI, Membership Services, 555 East Wells Street, Suite 1100 • Milwaukee, WI 53202
Fax: (414) 272-6070 • E-mail: [email protected]
www.aaaai.org/alliedhealth
AAAAI-0916-339