If you cannot provide a valid email address, you must use a print application. The print application can be downloaded here. It is STRONGLY suggested that you provide a valid email address that you check on a regular basis as many member benefits are transmitted electronically and depend on email transmissions.

Please DO NOT use this form to pay your NLA membership dues. If you are or have been a member of the NLA in the past please use this link.

PLEASE READ BELOW, YOUR APPLICATION WILL BE
IMMEDIATELY REJECTED IF:

Any required section is not completed.
You provide false or misleading information.
You attempt to circumvent any data validation implemented by the system.

NLA Membership Application

Choose a Membership and Payment Type

Regular Membership (1 year @ $195.00 OR 3 years @ $510.00 ) is available to any appropriately credentialed health professional engaged in the treatment of patients with lipid disorders or involved in research or educational activities relating to lipid disorders.
1 year(s) @ $195.00
3 year(s) @ $510.00
3 year bundle @ $1000 see details

International Membership (1 year @ $195.00 OR 3 years @ $510.00) is available to any appropriately credentialed health professional who is engaged in the treatment of patients with lipid disorders or involved in research or educational activities relating to lipid disorders and lives in a country outside the United States. As an International Member, you will receive all mailings electronically.
1 year(s) @ $195.00
3 year(s) @ $510.00

Industry Membership (1 year @ $195.00 OR 3 years @ $510.00) is available to representatives of industry (employees or contractors) ONLY if their job responsibilities do not include promotion of or participation in activities directly related to sales and marketing of products or services to health professionals or patients.
1 year(s) @ $195.00
3 year(s) @ $510.00

Personal Information

Courtesy Title:

First Name:

Middle Name:

Last Name:

Suffix:

Email:

Degree:

Other Degrees

Job Title:

Date of Birth:

Are you interested in pursuing certification in the field of Lipidology?

NLA Account Information

The following two fields will establish your web account preferences, allowing you to access members-only features on our website. If the username you select is taken, we will assign you a variation on your selection below. Please allow 48 to 72 hours for new web accounts to become active. You can use an email address as your username; but be aware that your username will displayed publicly with all your activity on the website and so your email will essentially be public information. We recommend against this.

Username:

Password:

By applying for membership in the NLA, you are agreeing that we may communicate with you INDIVIDUALLY by email, fax or land mail for purposes directly related to your membership such as purchase receipts, membership information and other purposes related to the maintenance of your account. Additionally, by default, you will be subscribed to our electronic communications such as newsletters, meeting announcements and educational opportunities which will be sent most often via email and on rare occasions may also be sent by facsimile. If you do not wish to receive these communications, you may uncheck the boxes below. You may change these preferences at any time once your membership has been activated. We hope you'll stay subscribed. We promise to keep our communications concise, relevant and worth reading.

I authorize the NLA to send me facsimile communications related to my membership and the association ( 3-4x per year )

I authorize the NLA to send me email communications related to my membership and the association ( 1-3x per week, depending on options selected )

Contact Information

Choose mailing address:

Office Address

If you would like to be included in our Find a Member search tool on Lipid.org and where applicable, the Find a Lipid Specialist search tool on The Foundation of the NLA’s LearnYourLipids.com, please include your office address.

Organization:

Country:

Street Line 1:

Street Line 2:

City:

State:

Zip/Postal Code:

Phone:

Fax:

Home Address

Country:

Street Line 1:

Street Line 2:

City:

State:

Zip/Postal Code:

Phone:

Fax:

About Your Practice

Profession:

Ethnicity:

Describe Your Involvement with Clinical Lipidology:

Type of Practice:

Professional, Practice, or Organization Website (if applicable):

Education

College:

Graduate:

Medical:

Internship/Residency:

Fellowship:

Postgraduate:

Degree:

Year:

Certifications and Licensure

License State:

License Number:

Board 1:

Board 2:

Board 3:

Present Medical School/Hospital Affiliations/Appointments:

Year Issued:

Year Obtained:

Payment Information

Promo Code:

How did you hear about the NLA?

Cardholder's First Name:

Cardholder's Last Name:

Card Type:

Card Number:

Expiration Date:

CVV:

Zip/Postal Code:

By checking this box (you must check to proceed), you indicate that you have read the membership criteria on the foregoing page. You also certify that all of the information provided in this application is true and correct to the best of your knowledge. Your IP address ( 54.144.24.41 ) has been recorded for security purposes.

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Publish Date:

Friday, January 1, 2016 - 02:00

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new_practice

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PLEASE READ BELOW, YOUR APPLICATION WILL BE IMMEDIATELY REJECTED IF:

NLA Membership Application

Choose a Membership and Payment Type

Personal Information

Meeting Registration Information

NLA Account Information

Contact Information

Office Address

Home Address

About Your Practice

Education

Certifications and Licensure

Payment Information

PLEASE READ BELOW, YOUR APPLICATION WILL BE
IMMEDIATELY REJECTED IF: