Membership Checkout

changeMembership Level
You have selected the Sustainer Membership membership level. For those who can afford a Clinical Membership but would like to give a little more. The price for membership is $200.00 now. Membership expires after 1 Year. Do you have a discount code? Click here to enter your discount code.
Discount Code

changeMembership Level

You have selected the Sustainer Membership membership level.

For those who can afford a Clinical Membership but would like to give a little more.

The price for membership is $200.00 now.

Membership expires after 1 Year.

Already have an account? Log in here.Account Information
Member Username This is a personal user identification for your GPALA website profile and will not be displayed anywhere else Password Confirm Password E-mail Address Confirm E-mail Address Full Name LEAVE THIS BLANK

More Information

Show in Member Directory Yes

First Name *

Last Name *

Nickname

License Type *

License Other

only fill out if you chose 'Other' from the License Type above

License Number

Year of Licensure *

Additional Licenses, Accreditations and Certifications

please separate each license with a comma

Supervisor Name

Supervisor License Number

Specialties *

click the teal box to choose multiple specialties

Professional Website Address

Office Address

Office City

Office Zip

Office Phone *

Office Email

Home Address

Home Phone

Home Email

If possible, I prefer to receive my GPALA newsletter: *

If you’d like to be more involved in GPALA please tell us how.

Billing Address
First Name - Last Name Address 1 Address 2 City State Postal Code Country Phone

We Accept Visa, Mastercard, American Express and DiscoverPayment Information
Card Type Card Number Expiration Date / CVV (what's this?) Discount Code

Processing...