Membership Application Name* First Last PhoneMailing Address* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenUsername Enter your preferred username.Email Address* Enter Email Confirm Email Membership Type* FELLOW ASSOCIATE STUDENT PHYSICIAN A PA practicing under the supervision of a board certified/board eligible dermatologist. Eligible to vote and hold office.A PA that does not practice under a board-certified dermatologist OR a non-PA allied health provider. Eligible for committee or liaison positions. Not eligible to vote or hold office.Currently enrolled in an accredited or AAPA approved PA program. Not eligible to vote or hold office.Entitled to address the Board of Directors. Not eligible to vote or hold office.FELLOWA PA practicing under the supervision of a board certified/board eligible dermatologist. Eligible to vote and hold office.NCCPA number* FL License number (required for eligibility to hold office) Supervising dermatologist name* Supervising dermatologist license number* FL License LookupSupervising dermatologist license number* ASSOCIATEA PA that does not practice under a board-certified dermatologist OR a non-PA allied health provider. Eligible for committee or liaison positions. Not eligible to vote or hold office.Credentials* PA NP Speciality Dermatology NCCPA number State license number STUDENTPA School* Expected Graduation Date MM slash DD slash YYYY PHYSICIANCredentials* MD DO Speciality Board Certified Dermatologist FSDPA Agreement InformationBy submitting content, you represent and warrant that you own the proprietary rights, including but not limited to the copyrights, to that content, and that the reproduction, public display and performance, distribution and preparation of derivative works of that content, by FSDPA or thereof, will not infringe any third-party rights or any applicable law. You agree to defend, indemnify and hold harmless FSDPA, directors, officers, employees, agents and other representatives from and against any and all claims, demands or proceedings (including but not limited to legal costs and fees) in the event of your breach of this representation and warranty.Accepted Terms* I agree to the above terms. HiddenRCP expiration MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ