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AKMG 2009 JAN PALACE ON WHEELS TRIP
 

   AKMG Membership Application

Last Name
First Name
Address
City
State
Zip
Home Phone
Office Phone
Fax
E-mail
Specialty
Medical College
Year Entered
Spouse Name
Please fill out a separate form, if spouse is a physician and applying for Joint Membership.
[ ] Annual Membership $50
[ ] Life Membership $500
[ ] Joint Annual Membership (Couple) $75
[ ] Joint Life Membership (Couple) $750
[ ] Resident/Fellow Membership $10
[ ] Student Membership No Charge
[ ] Please make check payable to “AKMG” and mail it to:

AKMG Membership Dues
P. O. Box 74703
Clevland, OH 44194-4703

 

     You can download the membership form from this link:     Adobe Acrobat (PDF) format







 
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