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IMASC Home : Membership : Membership Application.
  Applying for Membership : Step by step instructions.
 
  • Complete this Membership Application online
  • Submit this Application Online
  • Payment of Membership Dues (applies to Paid Membership Categories)
  • Pay by Check:
    • After submitting your application online, print the completed Membership Application and mail this printed version of the completed application along with a check payable to IMASC for Membership dues to:
           IMASC,
           P.O.Box 3006, Cerritos, CA 90703
           Phone: 562-698-7599
           Fax: 562-696-4266
    
 
Please note that IMASC is a nonprofit organization and the membership dues are fully tax deductible.
Our Non-Profit Tax Exempt ID is 330044199.
   
  Fields marked with an asterisk * are required.
  Login Detail..
  UserID* : eg.sam_001,alex2001 etc.
  Password* :
  Re-type Password* :
       
  Referral from :
  Membership Type* :
Individual Life ($500)   Annual ($100)
Medical Student (No fee) Aux (No Fee)
  Last Name* :
  First Name* : Middle     Title
  Date of Birth* :     Gender   F
       
  Mailing Address - Home
  Address* :
  City* : State* : Zip*
  Phone* : e.g. 408-123-2345   
  Fax : e.g. 408-123-2345   
  EmailID* :
       
Office Address Same as Home Address
  Address :
  City : State : Zip
  Phone* : e.g. 408-123-2345  
  Fax : e.g. 408-123-2345
  EmailID* :
   
  Specialty* :
  Subspecialty :
   
  Medical School Attended
  Country : USA Canada India Other
 
School Name* :
  Location : Year Of Graduation
       
  Residency Training
  Name of Program :
  Location : Year Completed
       
  Fellowship Training
  Name of Program :
  Location : Year Completed
       
  Medical License : Active Inactive Surrendered Not Applicable
  License State :
       
  Ever surrendered a medical license under the threat of a disciplinary action by any Medical Board: Yes  No
       
  Spouse Name :
      Is Spouse Physician Yes  No
       
 
Are you Medical Student, Resident or Fellow?
Anticipated Year of Completion :
 


Note:
Medical Students, Residents and Fellows:

To qualify for a free membership to MSRF section, please send us copy of ID issued by the Medical School or the training hospital.

You can either upload ( ) a copy of your ID
or send it to us by mail on this address
     IMASC,
     P.O.Box 3006, Cerritos, CA 90703
     Phone: 562-698-7599
     Fax: 562-696-4266