AKMG Membership Application

Do you live and practice in North America
First Name
Last Name
Address
City
State
Zip
Home Phone (xxx) xxx - xxxx
Office Phone (xxx) xxx - xxxx
Fax (xxx) xxx - xxxx
E-mail
Specialised In
Medical College
Year Entered
Spouse Name
explain your link to Kerala - whether by "birth, education, parents, marriage"
Membership type
 
 
Please fill out a separate form, if spouse is a physician and applying for Joint Membership.
[ ] Life Membership $500.00
[ ] Joint Life Membership $750.00
[ ] Annual Membership $50.00
[ ] Joint Annual Membership $75.00
[ ] Resident / Fellow Membership $10.00
[ ] Medical Student Membership No Charge
Please make check payable to “AKMG” and mail it to:
AKMG Membership Dues
3365 Beaufort Drive,
Bethlehem, PA 18017-1961
You can download the membership form from this link:     Adobe Acrobat (PDF) format
  Word (DOC) format