PSAA Membership Application

Membership Application

To join PSAA, you must first send in a completed application with your membership dues.

To join PSAA you can either fill out this form and submit, you can then use the “BUY NOW” button below to be redirected to a secure site where you can pay by credit card. Or, if you’d rather send a check, please print out this page, complete the application and mail it in with your payment.

A membership in PSAA belongs to the practice; however, please fill in the name of your office administrator or manager who will be representing your practice. This membership is transferable in the event of staffing changes.

Membership Application

Before submitting this form, please print out this page and mail it to the PSAA address below.

MANAGER'S NAME*
PrefixFirstLastSuffix
PRACTICE OR PHYSICIAN EMPLOYER'S NAME *
PrefixFirstLastSuffix
MAILING ADDRESS *
Street AddressCityZip Code
State / Geographical Division
OFFICE TELEPHONE*
OFFICE FAX
HOME TELEPHONE
E-MAIL ADDRESS*
Website
REFERRED BY
Please Select one:
- MEMBERSHIP RENEWAL
- NEW MEMBERSHIP
* Required. Please use the BUY NOW button below to purchase a membership plan.

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Membership Dues:
Annual Membership Dues – $150

PURCHASE ONLINE

MAIL APPLICATION AND CHECK TO:

PSAA
6324 Fairview Ave N
Crystal, MN 55428

Print page:

Membership Application

Membership Application

Member Login