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 Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe
• 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)
  • Associate Member ($300.00/3 years)
  • Pathology Asst/Trainee ($150.00/3 years)
  • Resident ($75.00/3 years)
• TOTAL
  $0.00
• CREDIT CARD
  American Express

  Discover

  MasterCard

  Visa

  Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 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.