Interviewee

Renewal Form 7/1/2020 - 7/30/2021

ALBANIAN AMERICAN MEDICAL SOCIETY
11 Cambridge St., Burlington, MA 01803
www.albamedsociety.org
secretary@albamedsociety.org
Phone: 617-999-7776

By filling out this membership application you are stating your honest intentions to join our society and pay the membership dues each year according to the category you are associated with (see below). Upon receiving your application, we will review your application and approve or disapprove it within 5 business days.

All rejected applicants will have their application fees refunded.

Please fill out only those fields where changes have occurred since last year

 

Gender
How many years have you held this position?
Has your application for membership in a medical society ever been disapproved, or have you ever been suspended or expelled from membership in a medical society? This question will not affect your odds of being approved to our society.
Has your license to practice medicine in any state ever been revoked or suspended? This question will not affect your odds of being approved to our society.
Have you ever been convicted of a felony? This question will not affect your odds of being approved to our society.
Are you Board Eligible/Certified in the USA?
I wish to apply for membership to the Albanian American Medical Society and pay the dues listed below for my category.
Are you a student?

Your Signature

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