STUDENT OBSERVEE REGISTRATION AAPI Student Observee Registration Form Only for International Medical Graduates who are currently in the United States.Name* First Last Address*City*State*Zip*Country*USAEmail* Phone*Are you a Medical Student?* Yes No Which year?*Name of the Medical College?*Which year did you graduate?*Current Position*Which State in USA would you prefer for Observership? (Please give 3 choices)*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingFor multiple selection, press CRTL key on your keyboard and select 3 states.Which specialty you are interested in applying for observership?*When would you like to start the observership? (One month Period)*Please read the Rules and Regulations before submitting the application. Please note that the initial deposit is non-refundable. AAPI will not sponsor VISA for International Medical Graduates.Paying By* Check Credit Card Initial Deposit* Price: AAPIUSA 600 Enterprise Dr., Ste. 108 Oak Brook, IL 60523 Check payable to: AAPICredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Consent* I agree to the privacy policy mentioned on https://eventsnew.aapiusa.org/observership-program/.The Online Payment Terms constitute a contract between you and AAPI. Please read them carefully. You may either accept or decline the Terms as indicated at the bottom of this page, but to make payment using the Services you must accept the Terms by clicking “I Accept”. All payments of AAPI services using the online credit cards are subject to the following conditions. AAPI accepts the following cards: American Express Discover MasterCard Visa You are paying today $200 as initial deposit for the observership and valid for up to one year. The remaining balance of $1300 will be accepted only by check and needs to be paid before you start observership. The cancellation fee is $100, but if AAPI can’t get a mentor for you, there will be no cancellation fee. You warrant that: You are 18 years of age or over. You have the appropriate authority to validly accept the Online Payment Terms and are able to and will meet your obligations in relation to these Terms. The credit card used in connection with the Services is issued in your name or you are authorized to use the credit card. You will pay the credit card issuer all charges incurred in the use of the Services. The information supplied by you is true and correct. When you complete the online payment form, funds will be deducted from your credit card in USD currency. All payments are debited to AAPI. Due to the way transactions are processed by the external banking sites, there may be delays of 1-3 days in updating your payment in AAPI’s records. AAPI does not store in any way your credit card details. Confirmation: If successful, you will receive a confirmation notice of your completed payment. If unsuccessful, you will be advised that your payment has failed. AAPI will not be advised why a payment has failed; therefore, you should contact your credit card provider for details. If your payment fails, please use one of the other payment methods, a check to pay your balance. By using online credit card for this transaction, you accept and consent to your personal data being provided to the AAPI for sole purpose of offering and administering the online payment. We respect the privacy of every individual who visits our site. The AAPI’s Terms and Conditions for online credit card payments are subject to change at any time. Each transaction shall be subject to the specific Terms and Conditions that were in place at the time of the transaction. If you have any questions or concerns, please contact us by email at info@aapiusa.org. Important security note: Never transmit credit card information by e-mail.Please upload your Visa for Verification*Max. file size: 512 MB.
