Reactivation Form

Your Name*
First Last
Date of Birth*
Email Address*
Business Address*
Street Address Address Line 2 City State ZIP Code
Home Address*
Street Address Address Line 2 City State ZIP Code
Year(s) of previous membership in AAP:*
Discipline:*
License Information:*
State Number
Disclosures
Has your license to practice ever been limited, restricted, suspended, voluntarily surrendered, revoked, or not renewed?*
- Yes
- No
Have you ever been reprimanded by a state licensing agency?*
- Yes
- No
Are there any actions pending with respect to your license?*
- Yes
- No
Are you under investigation by any licensing or regulatory agency?*
- Yes
- No
If you answered “Yes” to any of these questions, please explain:
Steps to Reactivation
Copy of your current license
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.
Proof of previous membership
This can be in the form of: Certificate of Membership; Cancelled checks in payment of dues; Various written communications from the Academy indicating membership; or Validation of a current Academy member as to your prior membership.
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.
There is a reactivation fee of $25.
- Reactivation Fee
Total
$0.00
Billing Information
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State ZIP Code
Billing Email*
Billing Phone*
Credit Card

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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Disclosures