AAPLOG MEMBERSHIP APPLICATION/MEMBERSHIP RENEWAL

AAPLOG Mission Statement

As members of AAPLOG we affirm:

1.  That we are responsible for the care and well being of both the pregnant woman and her unborn child.
2.  The unborn child is a human being from the time of fertilization.
3.  That elective disruption of the human conceptus at any time from fertilization onward constitutes the willful destruction of an innocent human being, and that this procedure will have no place in our practice of the healing arts.
4.  As physicians trained in both the art and science of the medical practice of obstetrics and gynecology, we are deeply concerned about the profound, adverse consequences that unrestricted abortion, physician assisted suicide and euthanasia  impose on women, unborn babies, children, and families. 

Therefore, we pledge to use our talents and skills to educate our patients, the public, our colleagues, and our students in order to promote respect for life in all stages of development; and, thus, to enhance the well-being of our entire society.

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I am in agreement with the Mission Statement.

Signature:________________________________________

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Membership in this organization shall be open to all physicians who have completed an ACGME or AOA approved OB/GYN residency program. We welcome as Associate Members any other physician or para-medical person who agrees with our mission statement.

Name: ______________________________Office: Address _______________________________

City_______________ ___ State ___  Zip ___________ Office phone________________________

Send AAPLOG mail to the following address:(if different)__________________________________

E-mail address: _____________________   Include name, office phone # on website? Yes ___ No___   

Are you currently receiving email from AAPLOG?  Yes ____   No____
 

OB/GYN Member:  M.D.___ D.O.___ OB/GYN Sub-Specialty _________________________

ACOG Member: ___ ACOOG Member: ___ Board Certified: ___ Board Eligible: ___ Retired: ___

Annual Dues:     Active Members:                 $100.00                   Dues can be deducted as a business

                            Retired Members:                $100.00                    expense.  Receipt desired? Yes ___

                            Resident Members:              $ 10.00   

Non OB/GYN Associate:  MD___DO___ Specialty ___________________ Nurse_____ Other______

No dues required for associates.  We suggest contribution of $25 to cover mailing expenses.  Contribution of any amount accepted.  We are a 501 C3 organization.  We will send a tax exempt receipt for donations if requested.

Please make checks payable to AAPLOG at address below

For credit card, give Visa/Mastercard #___________________________Exp Date_________

Billing Zip______

Signature:____________________________________

EXECUTIVE OFFICE: AAPLOG    339 River Avenue, Holland, MI 49423

Phone: (616) 546-2639   Fax: (616) 396-3160   E-Mail: info@aaplog.org