Application for Membership

Thank you for recognizing the importance of supporting your local pathology community and applying for membership in the Pacific Northwest Society of Pathologists. Your participation and financial support is essential as we continually strive to strengthen our organization.

Contact Information

Name:

First

Last

Title:

Practice/Group Name:

Address:

Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodeCountry

Phone:

Area Code

Phone Number

E-mail:*

Education Information

List schools and hospitals, years attended, and degrees received

Medical School:

Residency:

Internships:

Professional Information

Are you certified by the American Board of Pathology?

Yes

If yes, when and in what specialty?

Are you certified by the Royal College of Physicians & Surgeons?

Yes

If yes, when and what specialty?

Do you limit your practice to pathology?

Yes

Do you limit your practice to clinical pathology?

Yes

Special training and experience in pathology:

Membership Category

Membership Dues:*

Active Member ($300/3 years)

Associate Member ($300/3 years)

Pathology Asst/Trainee ($150/3 years)

Resident ($75/3 years)

Total:

Please verify:

Upon completing the form and clicking "submit," you will be directed to PayPal to make the payment. You do not need a PayPal account to make a payment.

INQUIRIES: Contact Darla White, Association Executive, at the PNWSP Office at 206-956-3642 or email admin@pnwsp.org.

Supporting the practice of pathology in the Pacific Northwest