<center>
	<h2>
		Contact AAPS</h2>
	5550 West Executive Dr., Suite 400<br />
	Tampa, FL 33609<br />
	(813) 433-2277<br />
	Fax - (813) 830-6599<br />
	<a href="http://www.mapquest.com/maps/map.adp?searchtype=address&amp;country=US&amp;addtohistory=&amp;searchtab=home&amp;formtype=address&amp;popflag=0&amp;latitude=&amp;longitude=&amp;name=&amp;phone=&amp;level=&amp;cat=&amp;address=5550+West+Executive+Dr.&amp;city=Tampa&amp;state=FL&amp;zipcode=33609" target="_blank"><font color="#336633">Click for a Mapquest&reg; map</font></a> <a href="http://www.aapsus.org/downloads/AAPS_Directions.pdf" target="_blank"><font color="#336633">Click for a local map</font></a>
	<p style="text-align: center;">
		Items in <font color="#ff0000">red</font> are always required.</p>
	<p style="text-align: center;">
		<b>If you need information about Board Certification or Recertification please visit <a href="http://www.abpsga.org/">ABPS</a></b></p>
<script language="javascript" src="/includes/js/forms.js" type="text/javascript"></script>	<form action="http://wb1.webforms.net/formpost.html?cid=67&amp;tid=2" method="post" name="f1" onsubmit="return checkContactForm(this);">
		<input name="forwardaddress" type="hidden" value="http://www.aapsga.org/contact/thanks.html" />
		<table border="0" cellpadding="2" cellspacing="0">
			<tbody>
				<tr>
					<td align="right" width="40%">
						<font color="#ff0000">First Name:</font></td>
					<td align="left" width="60%">
						<input autocomplete="OFF" maxlength="50" name="items[First]" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">Last Name:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="50" name="items[Last]" /></td>
				</tr>
				<tr>
					<td align="right">
						Designation:</td>
					<td align="left">
						<input gtbfieldid="247" maxlength="50" name="items[Designation]" size="5" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">Address 1:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="50" name="items[Address_1]" /></td>
				</tr>
				<tr>
					<td align="right">
						Address 2:</td>
					<td align="left">
						<input autocomplete="OFF" maxlength="50" name="items[Address_2]" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">City:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="50" name="items[City]" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">State:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="2" name="items[State]" size="2" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">Zip Code:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="10" name="items[Zip]" size="10" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">E-Mail:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="50" name="email" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">Phone:</font></td>
					<td align="left">
						<input autocomplete="OFF" maxlength="50" name="items[Phone]" size="15" /></td>
				</tr>
				<tr>
					<td align="right">
						Fax:</td>
					<td align="left">
						<input gtbfieldid="248" maxlength="50" name="items[Fax]" size="15" /></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">Academy:</font></td>
					<td align="left">
						<select gtbfieldid="249" name="items[Specialty]"><option selected="selected" value="">-- Select One --</option><option value="Anesthesiology">Anesthesiology</option><option value="Emergency Medicine">Emergency Medicine</option><option value="Family Practice">Family Practice</option><option value="Geriatric Medicine">Geriatric Medicine</option><option value="Internal Medicine">Internal Medicine</option><option value="Orthopedic Surgery">Orthopedic Surgery</option><option value="Radiology">Radiology</option><option value="Surgery">Surgery</option></select></td>
				</tr>
				<tr>
					<td align="right">
						<font color="#ff0000">I am interested in:</font></td>
					<td align="left">
						<select gtbfieldid="250" name="items[Interests]"><option selected="selected" value="">-- Select One --</option><option value="Academies of Medicine">Academies of Medicine</option><option value="Auxiliary">Auxiliary</option><option value="Auxiliary Scholarships">Auxiliary Scholarships</option><option value="Awards Information">Awards Information</option><option value="CME">CME</option><option value="Governmental Affairs">Governmental Affairs</option><option value="Meetings">Meetings</option><option value="Membership">Membership</option><option value="Recognition">Recognition</option><option value="Dues">Dues</option><option value="Other">Other</option></select></td>
				</tr>
				<tr>
					<td align="middle" colspan="2">
						<p>
							In the space below please provide your comments or question(s) and how you learned of AAPS.</p>
						<textarea cols="70" name="items[Comments]" rows="8"></textarea><br />
						<br />
						<input name="submit" style="text-align: center;" type="submit" value="Submit" /></td>
				</tr>
			</tbody>
		</table>
	</form>
</center>
