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New Member

Account Information

Name:	(*)
Email:	(*)

Other Information

Position/Title
Department
Institution
Private?	yes no
address	(*)
City	(*)
State	(*)
ZIP	(*)
Country	(*)
Office Phone
Medical School Affiliation (AAMC):
Name of Chairman:
Is your Chairman a member of AMSPDC	yes no
To whom do you report?
Name
Title
Are you the top administrator of your department?	yes no
Yes - (a confirmation letter will be required)	You will be redirected after payment to an upload area to attach a copy of your letter.
No - (please provide name and title of top administrator)
Membership	New Renewal
Member since
Membership Desired	Active Adjunct Emeritus
If new applicant, are you replacing someone at your institution?	yes no
Name of person you are replacing:
Are you a member of other professional organizations:	MGMA APA ACHE
Other