Enterprise Membership Interest Form

Enterprise Membership Interest Form

AAP Enterprise Membership (EM) is a multi-year collaboration with AAP national, your state AAP chapter, and your pediatric organization. For the most accurate cost estimate, please include all member-eligible physicians in your organization. Advanced practice providers are welcome to join as well!

EM offers member benefits and services to the individual and organization. Submit this form with a roster and AAP will contact you shortly. Thank you for your interest.

Organization

Organization Name*

Type of Organization or Division*

Eg. academic institution, hospital, health system etc.

Select

Organization website*

Organization Street Mailing Address*

State*

Select or enter value

County

Required for organizations in New York and California

Select or enter value

Primary Contact Person

Name*

Title at Organization*

Email*

Phone Number*

Phone

Contact Preference*

Phone

Approximately how many people in your organization are eligible for AAP membership?*

This number should include all MDs, DOs, PAs and NPs. Please do not include anyone in training.

To provide a full cost estimate, we require the first and last name, email address and birthdate for each eligible provider in your organization.*

Will you be able to provide this information?

Yes, I can provide a roster now.

Yes, I can provide a roster at a later time.

No, I will not be able to provide that information.

Submit your Roster

Submitting your roster now is optional, but it will allow us to provide a more accurate price estimate for your group. If you choose not to submit your roster now, you will be required to submit it later as part of the membership activation agreement.

Please make sure your roster is in Excel format and includes the following:

all member-eligible physicians and providers at your organization (including PAs and NPs)
first and last name for all individuals
email address for all individuals
birthdate for all individuals

Drag and drop files here or

Please provide any additional comments.

Send me a copy of my responses

Privacy Notice|Report Abuse