Online Registration Form

Welcome! We invite you to join your professional organization today and make MAPA one of your practice partners. The Academy provides a wealth of membership benefits to help you in serving your patients, your community, and your profession. Once you have selected your category of membership, complete the appropriate application, click on the "Join MAPA" button, and your application will be sent immediately. It’s that easy!

Once the application has been submitted, please allow two weeks for processing and assignment of your MAPA ID number. Please call MAPA, 517-336-7599, whenever you have questions about Academy membership and member benefits.

Click here to download a PDF version of the MAPA membership application.

Membership Types:

Fellow - A Certified PA within the state of Michigan

Student - Student of a board approved PA program

Associate - A PA who resides out of the state, is retired or otherwise inactive from clinical practice

Affiliate - Any non-PAs or non-PA students with a professional interest in the PA profession

Associate - A Certified PA who is not a fellow member of the AAPA

Select Membership Type:

Personal Information:
*^ First Name**
Middle Name
*^ Last Name**
*^ Email**
Date of Birth (mm/dd/yyyy)
Gender
* Your email address will not be made public or shared with third parties.

PA Certification Information:
State of Michigan PA License Number
PA Program Attended
Graduation Date (mm/dd/yyyy) enter first of month of your graduation
AAPA #
Specialty
Marital Status (S = Single M = Married D = Divorced)
Spouse First Name
Spouse Last Name

Home Address Information:
*^ Address Line 1**
Address Line 2
*^ City**
State:
*^ ZIP code**
Phone
Pager
Fax

Work Address Information:
Address Line 1
Address Line 2
City
State:
ZIP code
*^ Phone**
Pager
Fax
Supervising Physician

^* Select Preferred Mailing Address

Home Address
Work Address

Additional Information:
	Exclude my info from member directory
	I DO NOT WISH to be emailed PA Student Research Surveys
	I am available for Precepting
	I am available for Shadowing
I can be a resource for:
If Other enter here
I seek info about:
If you seek other info enter

Create Website Login:
*^ Desired User Name**
*^ Password**
*^ Confirm Password**

Payment Information:
*^ Full Name(as it appears on card)**
Credit Card Company:
*^ Credit Card Number**
Credit Card Expiration Date:	/
Solicitation Code
Amount to be charged

Once the application has been submitted, please allow two weeks for processing and assignment of your MAPA ID number. If you do not receive your new member packet after two weeks of applying, contact MAPA at 517-336-5778.

I hereby apply for membership in MAPA and, if accepted, agree to abide by the bylaws and PA code of ethics. I testify that the information in this application is true and accurate. Copies of bylaws and PA code of ethics available on our website under 'About MAPA'.

By clicking "Join MAPA" Button, you are digitally signing this application. I understand the services to which I am entitled and my membership expires 12 months from the date I join.