AKMG - Kerala Medical Graduates Association

AKMG Membership Application

First Name

Last Name

Address

City

State

Zip

Home Phone (xxx) xxx - xxxx

Office Phone (xxx) xxx - xxxx

Fax (xxx) xxx - xxxx

E-mail

Specialty

Medical College

Year Entered

Spouse Name

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

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}	$ 500.00
[ ] Life Membership {Couple}	$ 750.00
[ ] 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
	Word (DOC) format