A Payment Gateway must be set up before any payments will be processed. Membership Information You have selected the Regular Membership - 1 Year membership level. Regular membership is $170 annually, expiring Apr 30th of the following year. - Full year membership paid between Feb 1 and Oct 30: $170 The price for membership is $170.00 now. Membership expires on April 30, 2025. Account Information Username Password Show Password Confirm Password Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in here Important Information Cell Phone Work Phone Employer Name Your Position Licensure or Certification select option RN LPN PT OT Other If Other Name of the Person who recruited you to join ASPHP Email of Person who recruited you What is your age? select option 18 - 24 years old 25 - 34 years old 35 - 44 years old 45 - 54 years old 55 - 64 years old 65 years and older Prefer not to answer Years of experience working in SPHM select option Less than one year 1 - 3 years 3 - 5 years 5 - 10 years 10 - 15 years 15 - 20 years More than 20 years Prefer not to answer Employment Status select option Student Governmental sector Private sector Non-profit sector Retired Self-employed Prefer not to answer Select your professional role select option Allied health professional Technology Vendor (Sales, marketing, engineering, etc.) Non-licensed healthcare professional Nursing professional Other (write in) Prefer not to answer Select your employment setting select option Academic Assisted living Construction Consulting Design Home health Hospice Hospital Insurance & Risk management Long-term Care (SNF, nursing homes, assisted living, group residential home, foster care) Out-patient setting (private, hospital-based, non-hospital based) Vendor Other (Free text) Check all that apply Prefer not to answer Billing Address First Name Last Name Address 1 Address 2 City State Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands US Armed Forces Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone Payment Information Card Number Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 / 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Security Code (CVC) A Payment Gateway must be set up before any payments will be processed. Processing...
