AAPIOS Membership Application
Please fill out the application to update our database. Membership is only open to physicians and other health care professionals of Indian Origin practicing sleep medicine.
MEMBER PERSONAL INFORMATION
Full Name
*
First Name
Middle Name
Last Name
Degree:
*
Please Select
MD
DO Other degrees: (RPSGT, RRT, MBBS, BDS, MBA, PhD etc)
Gender:
*
Please Select
Male
Female
N/A
Practice Area
*
Please Select
Private Practice
Academics
Industry
Other(specify)
Current Address:
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
E-mail
*
example@example.com
Medical/Dental School:
Year of Graduation:
Residency Completion Year:
Fellowship Completion Year:
NOMINATED BY (When applicable) Last Name:
First Name:
Middle Initial:
AAPIOS Membership Number (If know):
www.aapios.org
AMERICAN ASSOCIATION OF PHYSICIANS OF INDIAN ORIGIN – SLEEP (AAPIOS) C/O GAUTAM SAMADDER MD, 99 N BRICE RD SUITE 350, COLUMBUS, OH 43213
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