Application

To view this form, please enable JavaScript in your browser.

Please complete the following form to apply for membership into PAD. Do not send payment for membership dues with this application. You will be billed upon enrollment as a member and dues are payable within 60 days after billing. Applications are acted upon by the Membership Committee of the Academy. Applicants will be notified of their application status within 30 days following the Committee’s decision.
Address Information
Educational Credentials
Professional Credentials
(max size 4 mb)
Membership

The contents of this box are for testing purposes. This box will be removed when the form goes live.
  • Select additional directory categories below by holding the "CTRL" key
  • Secondary categories may be subject to additional fees
 
 
 
 
 
 
 
   
 
 
 
 
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Credit Card Information

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address
Please click submit only one time.  The transaction may take several seconds.

Pennsylvania Academy of Dermatology and Dermatologic Surgery ©
777 East Park Drive, Harrisburg, PA 17111
Phone: (866) 650-3376 | [email protected] | sitemap I Privacy Policy I Terms of Use