Affiliate Membership Application

Affiliate – Membership Application

Individuals interested in the Pedorthic industry and PFA’s objectives.

Members include: Pedorthic Technicians, Podiatrists, Chiropodists, Physiotherapists, Chiropractors, Physicians, Residents, Interns, Shoe Retailers, Shoe fitters, Shoe Repair Techs, etc.

…..* Discounts on all PFA educational events
…..* Discounts on Resource Center Bookstore purchases
…..* Discounts on car rentals
…..* Online access for Current Pedorthic Magazine
…..* Educational opportunities
…..* Phone support for industry related questions…* Online access for Current Pedorthic Magazine
…..* Educational opportunities
…..* Phone support for industry related questions.

Membership Fee $245 plus tax per year (pro-rated)
Membership year runs May 1st – April 30th

Date of Application*
MM slash DD slash YYYY
Name*
First Last
Email*
Enter Email Confirm Email
Cell Phone*
Home Phone*
Home Address*
Street Address Address Line 2 City Province Postal Code
Employment Status*
- I am currently unemployed
- I am working in a pedorthic or related busniess
- I am currently working in an industry not related to pedorthics
Company Name*
Position in the Company*
Company Address*
Street Address Address Line 2 City Province Postal Code
Company Phone*
Company Website*
Are you working as a health professional in any discipline?*
- No
- Yes
If yes, indicate which profession(s) and include any professional associations to which you belong.
Affiliate Membership Fee (Pro-rated)*
Please select the month this application is being submitted to ensure your membership rate is pro-rated.
Subtotal
$ 0.00 CAD
Total
$ 0.00 CAD
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Comments
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