NTLAPA’S

JOIN NTLAPA

Category of Membership Category of Membership New Renewal

Name

Email Address

Specialty

Business Address (for website)

Work Phone (for website)

Mobile Phone

Office/Business WWW/Web Address (to place on NTLAPA Website)

Medical School:

Residency Program

Please indicated how you learned about NTLAPA Charitable Foundation (NCF)

Are you interested in becoming actively involved? (Please circle one below) Are you interested in becoming actively involved? (Please circle one below) Yes, I would like to become actively involved, and have time to devote. Yes, I would like to become actively involved, but have limited time to devote. No, I do not wish to be actively involved, but do wish to take advantage of NCF membership benefits.

If you answered yes, what position or committee (membership, communications/website, scholarship/community, social) are you interested in?

Please check the box below. Please check the box below. I acknowledge and Agree. I would like to become a member of the North Texas Latin American Physicians Association (NTLAPA), and have filled out this application completely and accurately. I am submitting dues of $200 along with my application and agree that this information will held on my record for as long as I am a member. I will also follow the mission statement and bylaws passed by the organization which I have read. Bylaws

9 + 5 =

The NTLAPA Membership Fee will be $200 per year. This fee is non-refundable.

If you want to pay with check, please make checks payable to NTLAPA and mail them to PO Box 2362 Frisco, TX 75034.