Online Membership Application2022-10-14T07:21:48+00:00 Please enable JavaScript in your browser to complete this form.Membership Type *NewRenewalName *FirstLastCredentials *e.g. MD, NP, PA, RN, etc.Degree *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Membership Term 1-Year (2024)2-Year (2024-2025)Individual Membership (1-Year) *Physician - $100.00NP/PA - $50.00Affiliate - $50.00Fellows/Residents/Students are free - $0.00 Physician Membership ($100): Any physician licensed in North or South Carolina whose professional medical services are provided in part within post-acute or long-term care facilities in North or South Carolina. Eligible to vote, to be elected to the Board, and to hold office. NP or PA ($50): Any advanced practitioner (NP, PA) licensed in North or South Carolina whose professional medical services are provided in part within post-acute or long-term care facilities in North or South Carolina. Eligible to vote and to be elected to the Board. Affiliate ($50): This would include the IDT (Interdisciplinary Team i.e. Administrators, therapists, pharmacists, DON, RN) and LIPs (Licensed Independent Practitioners i.e. DDS, CNS, DPM) and Industry. Affiliate members may attend and speak at membership meetings but are not be eligible to vote or hold office. Student (free): Fellows, Residents, Post Graduate or Undergraduate Medical, Nursing or Other Healthcare Programs. Student members may attend and speak at membership meetings but are not be eligible to vote or hold office. Individual Membership (2-Year) *Physician - $190.00NP/PA - $90.00Affiliate - $90.00Fellows/Residents/Students are free - $0.00 Physician Membership ($100): Any physician licensed in North or South Carolina whose professional medical services are provided in part within post-acute or long-term care facilities in North or South Carolina. Eligible to vote, to be elected to the Board, and to hold office. NP or PA ($50): Any advanced practitioner (NP, PA) licensed in North or South Carolina whose professional medical services are provided in part within post-acute or long-term care facilities in North or South Carolina. Eligible to vote and to be elected to the Board. Affiliate ($50): This would include the IDT (Interdisciplinary Team i.e. Administrators, therapists, pharmacists, DON, RN) and LIPs (Licensed Independent Practitioners i.e. DDS, CNS, DPM) and Industry. Affiliate members may attend and speak at membership meetings but are not be eligible to vote or hold office. Student (free): Fellows, Residents, Post Graduate or Undergraduate Medical, Nursing or Other Healthcare Programs. Student members may attend and speak at membership meetings but are not be eligible to vote or hold office. I am interested in working on the committee(s) as created by the Board such as Education, Membership, Newsletter, and Public Policy.YesTotal$0.00Payment Method: *PayPalCheck to CPALTCPlease select which payment method you will use for your membership dues. If you are paying online, you must complete the payment information, which will be presented on the next screen after you submit this membership application data form.Submit
