American Tamil Medical Association

Membership Registration Form

Personal Information

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Gender*

Mobile Phone*

Office Phone

Email (Unique)*

Date of Birth*

Education & Training

Medical School Graduation Year*

Primary Speciality*

Residency Institution

Fellowship Institution

Membership Categories

Lifetime Membership ($150)

Medical Student ($75)

Allied Health Science ($100)

The information provided in this application is true and correct. I understand that the ATMA (American Tamil Medical Association) Membership Committee will review my information. If found not eligible for ATMA membership, I acknowledge that the fees paid are non-refundable. As a member of ATMA, I will abide by the ATMA Bylaws and Its Articles of Incorporation.

Payment

Membership Fee: $0.00