AKMG - Kerala Medical Graduates Association

AKMG Membership Application

Do you live and practice in North America

Yes No Please select

First Name

First name required.

Last Name

Last name required.

Address

Address required.

City

City required.

State

State required.

Zip

Zipcode is required.

Home Phone (xxx) xxx - xxxx

A value is required.

Office Phone (xxx) xxx - xxxx

Fax (xxx) xxx - xxxx

E-mail

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Specialty

Medical College

A value is required.

Year Entered

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Spouse Name

explain your link to Kerala - whether by "birth, education, parents, marriage"

A value is required.

Membership type

Please enter the string shown in the image in the form.

Please fill out a separate form, if spouse is a physician and applying for Joint Membership.

[ ] Annual Membership	$50
[ ] Life Membership {Single} ( Until 07/31/10)	$ 350
[ ] Joint Annual Membership (Couple)	$75
[ ] Joint Life Membership(Couple)( Until 07/31/10)	$500
[ ] 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
	Word (DOC) format