AIPNO MEMBERSHIP FORM Your Information Full Name Work Address Work City, State, Zip Work Phone Email Cell Phone Specialty Spouse Information (required for couple membership) Full Name Work Address Work City, State, Zip Work Phone Email Cell Phone Specialty Home Address Phone City / State / Zip Membership Membership --- Annual Individual Physician $50.00 Annual Couples Physician $100.00 Lifetime Individual Physician $100 Lifetime Couple Physicians $150 Lifetime Individual Associate $50 Lifetime Couple Associate $100 For associate membership free Payment Details By Paypal By Cheque Fellow Resident Medical Student