Application for Membership

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• 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 Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
• Phone
• Email*

• Education Information

  List schools and hospitals, years attended, and degrees received
• Medical School
• Residency

• Professional Information

• Are you certified by the American Board of Pathology?
  • Yes
  • No
• If yes, when and in what specialty?
• Are you certified by the Royal College of Physicians & Surgeons?
  • Yes
  • No
• If yes, when and what specialty?
• Do you limit your practice to pathology?
  • Yes
  • No
• Do you limit your practice to clinical pathology?
  • Yes
  • No
• Special training and experience in pathology:
• Membership Dues*
  • Active Member ($300.00/3 years) - $300.00
  • Associate Member ($300.00/3 years) - $300.00
  • Pathology Asst/Trainee ($150.00/3 years) - $150.00
  • Resident ($75.00/3 years) - $75.00
• TOTAL
  $0.00
• CREDIT CARD
  American Express

  Discover

  MasterCard

  Visa

  Supported Credit Cards: American Express, Discover, MasterCard, Visa

  Card Number Expiration Date Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code   Cardholder Name
• 
  INQUIRIES:
  Contact Linda Krause, Association Executive, at the PNWSP Office at (206) 956-3624 or send emails to admin@pnwsp.org.

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