Application/AAMA

Membership Application

I am applying for membership in the American Academy of Medical Administrators.
I am also applying for membership in one of the following Colleges (please check):

American College of Managed Care Administrators
American College of Cardiovascular Administrators
American College of Healthcare Information Administrators
American College of Oncology Administrators
American College of Rehabilitation, Orthopedic and Neurological Administrators
American College of Home Health Administrators
American College of Contingency Planners
Uniformed Services, the Department of Veteran Affairs and the US Public Health Service

Your e-mail: (required)

Name in full:

Job title:

Date Appointed:

Organization Name:

Size & Type of Organization:

Organization Address:

Office Phone:

Fax Phone:

Name & Title of person or body
to whom you report:

Brief description of duties:

Home Address:

Home Phone:

Date of birth:

Gender:

Male Female

OCCUPATIONAL BACKGROUND

Name of Organization (1):

Location (1):

Job Title (1):

Date of Service (1):

Name of Organization (2):

Location (2):

Job Title (2):

Date of Service (2):

EDUCATIONAL BACKGROUND

Name of College/Location (1):

Major (1):

Degree Received (1):

Year Graduated (1):

Name of College (2):

Major (2):

Degree Received (2):

Year Graduated (2):

Vocational/Professional Background:
Include name of institution, license or certification info. and year graduated

Memberships and/or Awards, Published Articles or Books

THREE PROFESSIONAL REFERENCES:

Name:

Org:

Address:

Name:

Org:

Address:

Name:

Org:

Address:

Nomination Referred by:

	Self
	Other Person
	AAMA Affiliate \| Name:

Membership Type:

	$140 Nominee
	$20 Student

Credit Care Type:

Mastercard Visa AmEx

Credit Card #:

Expiration Date:

Statement of Integrity of Information

By selecting the submit button below, you are indicating that the information contained in this application accurately presents the data regarding your professional career.

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