Application - APPAP

Membership Application

ACTIVE MEMBERSHIP APPLICATION

CONTACT INFORMATION

PROGRAM INFORMATION

Sponsoring Institution and Affiliates for Postgraduate Program*

Point of Contact for Postgraduate Program*

Official Program Name*

Program Duration*

Application Deadline*

Interview Dates*

Start Date*

Class Size*

Year of First Graduate (or year of first expected graduate)*

Program Director (include credentials)*

Medical Director (include credentials)*

Faculty and Instructional Staff (list all with credentials)*

Clerical and Support Staff (list all with credentials)*

Professional Development Offered to Administrative Personnel*

Financial Resources to Support Postgraduate Program*

Facilities for Instruction (i.e. classroom, simulation lab, sleep rooms, clinical practice sites)*

Clinical Support Services (i.e. on-site pharmacy, laboratory, and radiology)*

Equipment, Supplies, and Workspace Provided to PA Resident/Fellow*

Learning Resources Available to PA Resident/Fellow Used Throughout Postgraduate Program*

Admission Policies and Procedures*

Evaluation Measures of PA Resident/Fellow Used Throughout Postgraduate Program*

Methods Used to Evaluate Postgraduate Program Effectiveness*

Healthcare Benefit*

Malpractice Benefit*

Vacation/Sick Time Provided*

CME Benefit*

Other Benefits Not Listed Above*

Postgraduate Program Website*

Methods of Recruitment*

Academic Certificate Awarded Upon Completion*

Disciplinary and Grievance Policies*

Method of Keeping Records of PA Resident/Fellow and Graduation*

Describe Postgraduate Program Curriculum (i.e. specific rotations, methods of instruction, learning objectives for didactic and clinical education components*

Upload supporting documents

PROVISIONAL MEMBERSHIP APPLICATION

CONTACT INFORMATION

PROGRAM INFORMATION

Sponsoring Institution and Affiliates for Postgraduate Program*

Official Program Name*

Point of Contact for Postgraduate Program*

Program Duration*

Application Deadline*

Interview Dates*

Start Date*

Class Size*

Year of First Graduate (or year of first expected graduate)*

Program Director (include credentials)*

Medical Director (include credentials)*

Faculty and Instructional Staff (list all with credentials)*

Clerical and Support Staff (list all with credentials)*

Professional Development Offered to Administrative Personnel*

Financial Resources to Support Postgraduate Program*

Facilities for Instruction (i.e. classroom, simulation lab, sleep rooms, clinical practice sites)*

Clinical Support Services (i.e. on-site pharmacy, laboratory, and radiology)*

Equipment, Supplies, and Workspace Provided to PA Resident/Fellow*

Learning Resources Available to PA Resident/Fellow Used Throughout Postgraduate Program*

Admission Policies and Procedures*

Evaluation Measures of PA Resident/Fellow Used Throughout Postgraduate Program*

Methods Used to Evaluate Postgraduate Program Effectiveness*

Healthcare Benefit*

Malpractice Benefit*

Vacation/Sick Time Provided*

CME Benefit*

Stipend Amount*

Other Benefits Not Listed Above*

Postgraduate Program Website*

Methods of Recruitment*

Academic Certificate Awarded Upon Completion*

Disciplinary and Grievance Policies*

Method of Keeping Records of PA Resident/Fellow and Graduation*

Describe Postgraduate Program Curriculum (i.e. specific rotations, methods of instruction, learning objectives for didactic and clinical education components*

Upload supporting documents

Membership

Membership Application

INDIVIDUAL MEMBERSHIP APPLICATION

CONTACT INFORMATION

ACTIVE MEMBERSHIP APPLICATION

CONTACT INFORMATION

PROGRAM INFORMATION

PROVISIONAL MEMBERSHIP APPLICATION

CONTACT INFORMATION

PROGRAM INFORMATION