"The purpose of the AAP is to advance academic physiatry by providing leading edge programs, products, and services"

AAP Corporate Partner Application

Company Name:

Address:

City: _________________________State: ________ Zip: ________

Phone: _______________________FAX:_______________________

E-Mail________________________WebSite:____________________

Contact Person:

Yes, I would like to be a Corporate Partner.
Enclosed is my check for $1700.00

Visa / MasterCard / AmEx: (please circle one)

Card Number: _______________________________
Exp. Date(MM/YY) ___________________________

Authorized Signature:

For Office Use Only:

Card Approval Code:

Processed by: ________________ Date: ____________

NOTE: Please attach any special requests you might have for listing your company's name in AAP publications.

Please make check payable to AAP and return to:

Association of Academic Physiatrists
1106 N Charles Street Suite 201
Baltimore MD 21201
Phone: (410) 637-8300
FAX: (410) 637-8399

Thank you for your support. *

* The AAP reserves the right to accept those Corporate Partners whose products and policies are in keeping with the objectives of the association.

Please print this form - print or type in responses - mail to above address.
Credit card payment may either be mailed, faxed or Emailed to the AAP office.

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