PA Membership Application
  1. You can fill out this Online form or you can print, fill out and mail with your check or credit card info to:
    Connecticut Orthopaedic Society
    Susan Schaffman - Executive Director
    26 Riggs Avenue
    West Hartford, CT 06107
    P: (860) 690-1146
    F: (860) 955-1178
    E: ctorthoexec@gmail.com
  2. First Name:(*)
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  3. Last Name:(*)
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  4. Practice Name:
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  5. Business Address:(*)
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  6. City, State Zip:(*)
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  7. Practice Web Address:(*)
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  8. Email:(*)
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  9. Phone:(*)
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  10. Fax:
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  11. Office Manager:(*)
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  12. Office Manager Email:(*)
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  13. Home Address(*)
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  14. City, State Zip:(*)
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  15. Home Phone:(*)
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  16. Date of Birth:(*)
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  17. Professional Information
  18. PA Program:(*)
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  19. CT License No.:(*)
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  20. Year Obtained:(*)
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  21. Supervising Physician's Name:(*)
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  22. For information only, not a condition of membership
  23. NCCPA Cirtified?
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  24. Member of AAPA?
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  25. Your card will be charged $150.00 for membership to the Connecticut Orthopaedic Society.
  26. Please Enter the Numbers(*)
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