Licensed Member Application - Armenian American Medical Society Armenian American Medical Society

Product Name

Personal Details

First Name*

Last Name*

Title (MD, PharmD, RN, etc...)*

Specialties*

Valid license to practice in your state

Yes
No

Board Certified In

Board Eligible In

Dental License Number

Medical License Number

Hospital Affiliations

Hospital Affiliations Active

Active
Retired

Private Details

Spouse's Name

Home Address

City

State

Zip Code

Phone Number*

Email Address*

Education Details

Undergraduate Education*

Undergraduate Degree*

Undergraduate Year*

Postgraduate Education*

Postgraduate Degree*

Postgraduate Year*

Residency*

Residency Year of Completion*

Fellowship*

Fellowship Year of Completion*

Postgraduate Training

Professional References

List of Professional References

Professional Reference	Phone Number

Professional Practice(s)

List of Professional Practices

Company	Address	City	State	Zip Code	Phone Number	Fax Number	Email Address	Website

Optional

Academic Position Held

Will you be interested in being a lecturer for AAMS Educational and CME meetings?

Yes
No

Receive Correspondence?

Home
Office

Will you be interested in mentoring a healthcare student?

Yes
No

AAMS' "Your Health" TV Program

Would you like to be a guest on AAMS’ “Your Health” TV program?

Yes
No

Armenian Language Proficiency

Visit https://aamsc.org/tv-programs/ for more information.

Payment Details

Membership Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address

Street Address Address Line 2 City State ZIP Code

I hereby authorize the Armenian American Medical Society (AAMS) to automatically charge my credit card on the first of every new year.

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