Central BMANA Membership

1

Select Membership Type

2

Personal Information

3

Address Information

4

Professional Information

5

Current Professional Position

Select all positions that currently apply to you

Practicing Medicine in America
Active clinical practice
Not Practicing in North America
Currently not in clinical practice
PhD
Doctor of Philosophy degree
Research Position
Active in medical research
Academic Position
Faculty or teaching role
Retired
From active practice
6

Declaration & Agreement

Accuracy of Information

I certify that all information provided in this application is accurate and complete.

Information Disclosure

I agree to disclose this information for BMANA membership registry and publication.

Communication Consent

I consent to receive communications from CBMANA regarding events and updates.

7

Signature & Date

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This date will be recorded with your signature

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