Membership Application

This form is for both regular and professional (diplomate or Fast-Track candidate) new members.

Non-subscription new member form

Please fill out and submit the form below to become a PINA member.
If you need more information about membership, see our membership overview page.
Payment is via PayPal - you do not need a PayPal account and can pay with credit or debit card.
  • Choose a user name for your PINA login.
    NOTE - after your payment is processed, a link to set your member login password will be e-mailed to you!
  • When is your birthday?
    What kind of PDC did you attend?
    Checking this box means you are giving permission for us to share your e-mail with other PINA members wishing to organize a hub in your area.
  • $0.00
    REMINDER - after your payment is processed, a link to set your member login password will be e-mailed to you!
  • This field is for validation purposes and should be left unchanged.
If you are unable to register online, you can print out our Membership Application Form and send it with payment to the address on the form.

Name