American Obesity Association - AOA Online Membership Application


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	AOA Online Membership Application

Membership Application Information (Required fields are marked in red.)

Select One: New Member Renewal (AOA Member ID: )

Mr. Ms. Mrs.

First Name:

Middle Name:

Last Name:

Title:

Company:

Address:

City:

State:

Zip:

Work Phone:

Home Phone:

Fax:

Email:

Website URL:

Occupation:

Dietitian/Nutritionist
Exercise Scientist/Health Fitness Professional
Health Educator
Nurse
Physical or Occupational Therapist
Physician
     Specialty:

Psychologist
Researcher
     Specialty:

Social Worker
Other

Membership Type:

Individual - Category 1 ($15)
Professional Provider - Category 2 ($90)
Obesity Specialty Clinic - Category 3 ($500)
Center of Excellence - Category 4 ($1000)
Corporation - Category 5 ($5000)
Non-Profit / Government / Small Business - Category 6 ($200)
Student - Category 7 (Complimentary)
     Field of Study:

     Institution:

Supporting Documentation

If you are applying for Membership Category 2,3,4, or 6, you must submit supporting documentation by U.S. mail indicating that you have met the criteria specified for your membership type. Mail your supporting documents to:

American Obesity Association
1250 24th St, N.W.
Suite 300
Washington, D.C. 20037

Read the criteria in the Membership Categories section of the AOA Membership web page. Your membership application will only be complete upon receipt of the necessary documentation.

Check this box if you have read and agree to comply with the Supporting Documentation Statement. The AOA reserves the right to reject or return incomplete applications.

Patient's Bill of Rights

If applying to Categories 2 through 5, all providers of professional services to persons with obesity must agree to abide by the AOA Patient's Bill of Rights.

Check this box if you agree to abide by the AOA Patient's Bill of Rights.

AOA's Online Professional Directory

Members enrolling in Categories 2 through 5 (Professional Provider, Obesity Specialty Clinic, Center of Excellence and Corporation) are eligible to be listed in the AOA Online Professional Provider Directory. The purpose of the directory is to help consumers find appropriate professional assistance.

Check this box if you are eligible and want to be listed in AOA's Online Professional Directory

Members listed in the Directory who agree to abide by voluntary guidelines established by the Partnership for Healthy Weight Management will be identified as such. Read the guidelines on the Partnership's website: www.consumer.gov/weightloss/guidelines.htm.

Check this box if you agree to abide by the Partnership's Voluntary Guidelines.

AOA Research Foundation Donation

If you would like make a donation to the AOA Research Foundation (AOARF), please indicate the amount of your donation. For information about the AOARF, click here.

Payment

Name on Credit Card:

First Name	Last Name

Billing Street Address:

Zip:

Total Amount Due:

Card Number:

Visa or Mastercard accepted

Expiration Date (mmyy):

Application by U.S. Mail

If you prefer to pay by check or money order, please print this page and include payment made to the American Obesity Association. Payment must be drawn on U.S. Banks in U.S. Currency. Mail application, any supporting documents and payment to:

American Obesity Association
1250 24th St, N.W.
Suite 300
Washington, D.C. 20037