Membership Checkout – America Nepal Medical Association

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Membership Information

You have selected the Physician membership type.

The price for membership is $100.00 now.

Account Information

Username

Password

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Email Address

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Medical School

Name of Medical School

City (Medical School)

Country (Medical School)

Start Year

Graduation Year

Residency Information

Residency Program

Residency Speciality

City (Residency Program)

Residency Start Year

Residency Graduation Year

Residency Visa Status (If Applicable)

Fellowship Information

Fellowship Visa Status (If Applicable)

Fellowship Program

Fellowship Speciality

City (Fellowship Program)

Fellowship Start Year

Fellowship Graduation Year

Specialty Information

Current Practice

Select One

Current Hospital Affiliation

Current Hospital City

Current Hospital State

Billing Address

First Name

Last Name

Address 1

Address 2

City

State

Postal Code

Country

Phone

Payment Information

Card Number

Expiration Date

Security Code (CVC)