Membership Registration

Please fill in the following form online. You can pay online via for membership and event dues. You need not have Paypal account for these registrations and can pay by any credit card on the Paypal site. The user login and password will help you check your paid dues, registrations discounts and easy signups for events. You can signup for the WAPI membership online membership form here.

Personal Section

*Last Name:
*First Name:
*Gender:	Male Female
Address 1:
Address 2:
City:
State/Prov:
Zip:
Country:
Home Phone:
Home Cell:
Home Fax:
Email1:
Email2:
Website:
Specialty:
Medical School:
Grad Year:
Photo:

Thank you for taking time to register.

Your Login Information

*User ID:
*Password:
*Confirm Password:
*Secret Question:
*Secret answer:

Password must be 6-8 Characters long.

Spouse Section

Spouse Name:
Gender:	Male Female
Spouse Email:
Spouse Contact:
Spouse’s Occupation:
Spouse’s School:
Grad year:
Can You Volunteer for WAPI?:	Yes No

Contact Admin if you wish to volunteer for WAPI.

Office Section

Office/Employer Name:
Office Address1:
Office Address2:
City/State/Zip:
Business Phone:
Business Fax:
Practice Limited To:
Accept New Patients?	Yes No

This information will be available for public and advertising Purpose.

Membership Section

*Registration Type:

*Price for Registration:
*Date of registration :
Communication Notes:

Select a registration type to pay for dues. Registration is applicable to end of the current calendar year.

Membership Qualification Questions.

Members of WAPI abide by its bylaws. To assist us in upholding bylaws, please provide the answers to the following questions.

Yes No

() () *1. Do you consider yourself a physician or allied health professional with Indian heritage? ( Please refer to WAPI’s bylaws at www.wapiusa.org)

() () *2. Have you had your membership in any professional organization revoked or denied? If yes, please explain on back page.

( The foregoing information is true and complete. Please fill in communication notes if you need to explain any of your answers.)

Note:
Membership is contingent upon WAPI’s governing body’s acceptance of the membership application. The endorsement, deposit or negotiation of an applicant’s check does not constitute admission in to or acceptance of membership by the WAPI. Checks received will routinely be negotiated and deposited. However if your application is not approved for membership by gov body, you will receive a refund from WAPI for the amount submitted. The review will occur at WAPI’s gov body meeting that follows receipt of your application.

Pay by credit card mail check

* Required

Website Design & Maintenance by Progressive Way Technologies
Non-Profit Web Hosting provided by myhosting.com