Membership Application

Preferred address for mailings/correspondence: Work Home

*Home address will be used for membership directory listing and all correspondence unless otherwise indicated above

___New Applicant ___Renewal Date of App: ____/______/_______

Name: __________________________________________________________

Company/Facility Name:_______________________________________

Business Address: ___________________________________________

City: _________________________ State:_____ ZIP:______________

Home Address: _____________________________________________

City: _________________________ State:_____ ZIP:______________

Home Phone (______)____________ Mobile Phone (_____)___________

E-Mail _________________________________________

Discipline: __EP __RN __RT __PT __OT __Dietitian __Physician

__Other:______

Area of Clinical Practice:

___Cardiovascular ___Inpatient ___Outpatient ___Both

___Pulmonary ___Inpatient ___Outpatient ___Both

___Cardiovascular and Pulmonary ___Inpatient ___Outpatient ___Both

___Wellness/prevention Other:____________________________

Does your work support your membership? ___ Yes ___ No

Is your program certified? ___ Yes ___No

Are you a member of AACVPR? ___ Yes ___ No

Number of employees in your program ______________

Membership Fees:

$25 Individual Member __________

$15 Student ____________ (Copy of Student ID required – submit with application)

Please mail check or money order payable to SACPR with printed application to:

Samantha Bishop M.Ed.

EAMC-Cardiac Rehab

Opelika, AL 36801-5422

(334) 528-1694 (phone) (334) 528-4797 (fax)

2000 Pepperell Pkwy