Florida Allergy, Asthma & Immunology Society


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Membership Application

Please print out the application below, fill it in and mail your check along with the documents listed at the bottom of the form to:

FAAIS
4909 Lannie Road, Ste. B, Jacksonville, FL 32218

Florida Allergy, Asthma & Immunology Society
4909 Lannie Rd. Ste. B ¨ Jacksonville, FL 32218
904/765-7702 ¨ Fax 904/765-7767
email: faais@aol.com

MEMBERSHIP APPLICATION

(Please Print or Type - information for FAAIS use and will not be released)

  NAME _______________________________________________________________

  PRIMARY OFFICE _____________________________________________________

      CITY ________________________________ STATE ______ ZIP _________

      TELEPHONE _____________ FAX _____________ EMAIL ________________

  SECONDARY OFFICE ___________________________________________________

      CITY ________________________________ STATE ______ ZIP _________

      TELEPHONE ______________ FAX ______________ EMAIL ______________

  HOME TELEPHONE __________________ NAME OF SPOUSE ___________________

  MEMBERSHIPS:   ___ FMA   ___ AMA   ____ ACAAI   ___ AAAAI   ___ ICAI

  PRACTICE ASSOCIATES ________________________________________________

  UNDERGRADUATE DEGREE

      SCHOOL ____________________________________________ YEAR _______

  MEDICAL DEGREE

      SCHOOL ____________________________________________ YEAR _______

  RESIDENCIES

      ____________________________________________________ YEAR ______

      ____________________________________________________ YEAR ______

      ____________________________________________________ YEAR ______

  BOARD CERTIFICATION

      BOARD _____________________________________________ YEAR _______

      BOARD _____________________________________________ YEAR _______

"Contributions or gifts to the Florida Allergy, Asthma & Immunology Society are not deductible as charitable contributions for Federal income tax purposes. However, dues payments are deductible by members as an ordinary and necessary business expense."

When submitting membership application, please enclose your check for $125, payable to: Florida Allergy, Asthma & Immunology Society, along with your Curriculum Vitae and a letter of recommendation from two of our FAAIS members, one of whom is not a practice associate, and a copy of your Board Certification in Asthma, Allergy and/or Immunology.

"Allergy Proceedings" is sent to active and affiliate members. All others must include the subscription cost of $18. Please contact the FAAIS office regarding any change in address.

4909 Lannie Road, Suite B • JACKSONVILLE, FLORIDA 32218
904/765-7702 • FAX 904/765-7767 •