Membership Form - Amsafrica

INSTITUTIONAL MEMBERSHIP APPLICATION FORM <br

Institution *

Contact Address *

City

State/Province

ZIP / Postal Code

Country

Head of Medical School *Name & Designation

Contact Email Address *official correspondence

Institutional Emailif different from above

Contact Tel Number *WhatsApp correspondence

Institution’s Website

Year of Accreditation (Medical Shool) *

Previous Member *YesNo

Membership Category Being Applied For *Regular MemberAffiliate Member

Signature *

Start signing your signature here

Date *

Day

Month

Year

NB – Please note that renewal / new membership fee is free for the year 2025

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