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:

Format: (000) 000-0000.

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?

If other, please specify:

Are you applying for a Corporate Membership?

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.

Membership

USDAnnual GAMPA membership

Signature