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