2025-2026 Membership Application Form Auxiliary to the National Medical Association

2025-2026 Membership Form
Name*

TitleFirst Name Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registration Information
Phone Number*
Format: (000) 000-0000.
Spouse

First Name Last Name
E-mail*
Auxillary
Region
ANMA Life Member*
I hereby apply for membership in the Auxiliary to the National Medical Association, Inc. and do hereby agree to abide by the laws governing this organization

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MEMBERSHIP FEES

Our fiscal year begins on October 1st, and we will gladly accept your dues on or after October 1st. ANMA Life Members are exempt from paying dues but shall pay convention registration fees.
SCHOLARSHIP FUND DONATIONS

A "TAX DEDUCTIBLE DONATION" is always appreciated and needed. Please select donation option and add to payment.
Check IndividualCredit or Debit Card IndividualLocal or State Auxiliary
$100 (Suggested)Other
Regular Member Dues $150.00Interim Member Dues $150.00Resident/Interns Spouse Dues $50.00Physician/Physician Spouse Dues $50.00
State Affiliation Dues $100.00Local Affiliation Dues $80.00
Regular Member Dues $175.00Resident/Interns Spouse Dues $60.00Physician/Physician Spouse Dues $60.00
State Affiliation Dues $120.00Local Affiliation Dues $100.00
All Members $300.00Guests $50.00
All Members $350.00Guests $325.00
$25$50$75$100
$25$50$75$100
Total Due (Check Payment)
prevnext( X )
Regular Members Dues 2
$175.00



Physician/Physician Spouse Dues 2
$75.00



ANMA Life Member
Optional

$100.00



Interim Member Dues 2
$175.00



Omega Mason/ Maude Bisson Donation
$25.00



Omega Mason/Maude Bisson Donation
$50.00



Omega Mason/Maude Bisson Donation
$75.00



Omega Mason/Maude Bisson Donation
$100.00



Alma Given Donation
$25.00



Alma Given Donation
$50.00



Alma Given Donation
$75.00



Alma Given Donation
$100.00



Subtotal

$0.00

Shipping

$0.00

Total

$0.00
Please mail forms with checks to:

ANMA

c/o Maria Bright - Financial Secretary

1703 South Thames Court

Greenville, NC 27858

Phone: (919) 641-6195
If assistance is needed to complete, contact the National office at nationaloffice@anmanet.org or 301-495-3779.

Should be Empty:

2025-2026 Membership Form

MEMBERSHIP FEES

SCHOLARSHIP FUND DONATIONS