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20 November 2008, 4:41:07 PM
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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 6765, Orange, CA 92863.
   
  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 ($1000)   Joint Physician Couple Life ($1500)
Annual ($100) Spouse Life ($500)  
Medical Student (No fee) Trainee (No Fee)
       
  Last Name* :
  First Name* : Middle     Title
  Date of Birth* :     Gender   M  F
       
  Mailing Address   Is this address your: Office  Home Both
  Address :
  City : State : Zip
  Phone* : e.g. 408-123-2345    Office  Home Both
  Fax : e.g. 408-123-2345    Office  Home Both
  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
  Licence 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 as applicable to the following address
IMASC, P.O. Box 6765, Orange, CA 92863.
       
     
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