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ADDRESS INFO
Membership Type *	PPS membership - new (regular) ($100.00 for period up to 01/01/2011) PPS membership - renewal (regular) ($100.00 for period up to 01/01/2011) PPS membership - new (resident or fellow) ($25.00 for period up to 01/01/2011) PPS membership - renewal (resident or fellow) ($25.00 for period up to 01/01/2011)
Payment System *	PayPal - PPS secure credit card payment - PPS
Your Name * Your First & Last name
Degree MD, PhD, MDPhD, other
Your E-Mail Address * A confirmation email will be sent to you at this address
Choose a Login Name (User ID) * It must be 2 or more characters in length and may only contain small letters, numbers, and the underscore '_'
Choose a Password * Must be 4 or more characters
Confirm your password * Enter password again
Country
State
City
Address 1
Address 2
ZIP
Department
Institution
Telephone (work)
Fax