AHPBA New Chapter Request

Please complete the following application for your Chapter to be formally considered for adoption by AHPBA. You may stop and save your work as you progress.

Application Requirements:

Chapter Contact Information
Chapter President Contact Information
List of Members (names and email addresses) - minimum of 6 AHPBA/IHPBA members
Copy of Bylaws
Description of Incorporation
Information for next meeting/program for members

1. Please complete the contact information for the Chapter President *This question is required.

First Name

Last Name

Credentials/Designation (MD, PhD)

Institution/Company

Email Address

Mobile Phone