Association of Indian Pathologists in North America
Membership Application

Please fill out the following form and print it using the file- print option on your browser.
First Name Middle Name Last Name Degree (e.g. MD, PhD)
Academic Title
Administrative Title
Speciality area
Medical School you attended
Mailing Address
Phone Fax
EMail Address
Amount Enclosed (Checks only, payable to AIPNA-$25 for one year for residents, $50 for one year others, $500 for lifetime)

Today's Date:

Print the form using the file- print option on your browser. Please print and save a copy for your record. Mail the form with your check to:
Rajal Shah, M.D.
2G332UH, 1500 East medical center drive
Department of pathology
Ann Arbor. MI48109-0054
USA


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