Affiliate Membership Registration Form
*fields are necessary

Affiliate Membership Fees (Please Select one)*

  1.  New Affiliate Membership Fee With Journal - United States  $187.00
    - New Affiliate membership fee includes application fee ($25.00),
    - annual dues ($110.00) and
    - journal subscription ($52.00).

  2.  New Affiliate Membership Fee With Journal - Outside the United States  $217.00
    - New Affiliate membership fee includes application fee ($25.00),
    - annual dues ($110.00),
    - journal subscription ($52.00) and
    - international postage ($30.00).

  3.  New Affiliate Membership Fee Without Journal - Inside or Outside the United States  $135.00
    - New Affiliate membership fee includes application fee ($25.00),
    - annual dues ($110.00) but without journal subscription.
Personal Information
*Last Name :
*First Name :
Initial :
*Correspondence Address :
  United States Non United States
*City :
*State/Country :
Zip Code :
Home Telephone :
Office Telephone :
Fax :
Cell No:
*Email:
*Date Of Birth:
Gender : Male Female
Journal Desired : Yes No
Professional Information
BOARD CERTIFICATION
Academic and Professional Degrees :
Name of Board :
Certification Date :
Professional Training
Professional
Institute :
From :
To :
Degree/Certificate :
 
AdvanceD oral and Maxillofacial Radiology
Institute :
From :
To :
Degree/Certificate :
 
other advanceD training
Institute :
From :
To :
Degree/Certificate :
 
 
 
 
 
 
© AMERICAN ACADEMY OF ORAL AND MAXILLOFACIAL RADIOLOGY
Postal address: P. O. Box 1010 Evans GA 30809-1010
  Maintained by Carmina Castro  
Last updated: October 23, 2008