Full Name:  Birth Year: 
             (First/Middle/Last)

AAP Fellow and Specialty Specialty Fellow

Chapter 2 annual dues: $165.00

Chapter 2 Affiliate Member -- non-board-certified in pediatrics

All rights and privileges of AAP Fellows except voting and right to hold office.
Chapter 2 annual dues: $165.00 (must accompany application).
** Please complete Academic History.

Emeritus Fellow (ill, >65 years of age)

$50.00

Fellow -Retired

$75.00

AAP Candidate Fellow

$120.00

AAP Resident Fellow, Medical Students, Medical Missionaries, Honorary Fellows, Post-Residency Training Member

No Chapter 2 dues.

Chapter 2 Life Member

May be any one of the above (please check appropriate block).
Chapter 2 dues: 10 X Annual Dues (must accompany application).

Your listing for the Directory of Members: Please make listing exactly as you want it published.

          Name:  
#1 Address
        Street:  
         Suite: 
City/State/Zip: 
  Phone Number: 
    Fax Number: 
E-mail Address: 
#2 Address
        Street:  
         Suite: 
City/State/Zip: 
  Phone Number: 
    Fax Number: 
E-mail Address: 
     Specialty:  Bd. Cert. Bd. Elig 
  Subspecialty:  Bd. Cert. Bd. Elig

        Street:  
City/State/Zip: 

       Medical School:  
            Year Grad: 
           Internship: 
                 Year: 
           Residences:  
                 Year: 
    Postgraduate Work: 
       Hospital Staff: 
Percentage of professional time devoted to pediatrics: %