Association Membership Registration

Basic Personal Information

Full Name*

First Middle Last

Date of Birth*

Gender*

Nationality*

Contact Number (Mobile)*

Contact Number (Office)*

Email Address*

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Residential Address (if different)

Street Address City State / Province / Region ZIP / Postal Code Country

Professional Details

Profession*

Medical Doctor

Dentist

Specialist

Other

Area of Specialization*

License Number*

Licensing Body (e.g., Bahamas Medical Council)

Year of First Registration*

Current Practice/Clinic Name*

Office Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Office Phone*

Office Email*

Payment

Membership Fee Tier:

{ID:50}

Total

Membership Levels*

Junior Physician - $50.00

Senior Physician - $100.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

I confirm that the above information is true and correct. **

I confirm that the above information is true and correct.

Agreements and Declarations

I have read and agree to the association's bylaws and code of conduct*

I have read and agree to the association's bylaws and code of conduct

I consent to receive updates and communications via email and SMS.*

I consent to receive updates and communications via email and SMS.

Signature*

Association Membership Registration

Basic Personal Information

Professional Details

Membership Type

Supporting Documents

Additional Details

Payment

Agreements and Declarations

Review Your Registration