Georgia Association of Minority Physician Associates Membership Application Form

Georgia Association of Minority Physician Associates Inc.

Dedicated to creating Diversity in Medicine
Who referred you to GAMPA?
Name

First NameLast Name
E-mail address
example@example.com
Best contact Number:
Mailing Address (special gifts or correspondence) :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear not required
What School do you currently attend/previously attend?
What would you like to experience with this organization?
Please select the type of membership?

PA-SPA-CNPMDOther healthcare provider
If other, please specify:
Are you applying for a Corporate Membership?

YesNo
If yes, please provide names, titles and emails of other associates who will represent your organization.
Please confirm that you agree to the membership fee below. Georgia Association of Minority Physician Associates Inc is a nonprofit organization dedicated to encouraging more diversity, equality and inclusion for all healthcare providers. We appreciate and thank you for your support.

YesNo
Membership

prevnext( X )
USDAnnual GAMPA membership
Signature

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