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AKMG Membership Application
Do you live and practice in North America
Yes
No
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
Select Membership
Annual Membership
Life Membership
Joint Annual Membership
Joint Life Membership
Resident/Fellow Membership
Student Membership
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
