PA Practice Owners Network Interest Form

First Name *

Last Name *

Organization *

Please provide the name of your organization or practice

Email *

License Number *

Please enter your PA license number

Professional Designation *

Enter required value PA-C PA PA-S MD DO FNP FNP-C PharmD Pre-PA

Specialty *

What is your primary specialty?

What type of practice ownership do you have? *

Examples of practice ownership include:

1. Majority owner of a PA Corporation
2. Minority owner of another medical practice or corporation

What type of relationship do you have with your supervising physician? *

Please describe the nature of your supervisory relationship. Examples include:

• I contract directly with my supervising physician
• I use a third-party firm to hire my supervising physician

What is your annual revenue? *

Please select the tier that best reflects your annual revenue.

$5,000 - $50,000

$50,000 - $100,000

$100,000 - $250,000

$250,000 - $500,000

$500,000 - $1,000,000

More than $1,000,000

Statement of Interest *

Please briefly describe your interest in joining the PA Practice Owners Network and what you hope to gain from the group.