New Membership ______        Renewal of Membership ______        New Update on Database ______

 

Type of Membership:   Life ___ Active ___ YPS ___ Associate (Resident) ___ Allied ___ Student ___

 

Name: _______________________________________________________________________________

 

Specialty: _____________________________________________________________________________

 

Home Address: _________________________________________________________________________

 

Office Address: _________________________________________________________________________

 

Home Phone/Fax: _________________________________   Cell #: ______________________________

 

Office Phone/Fax: _______________________________________________________________________

 

Email Home/Office: _____________________________________________________________________

 

Preferred way of contact:   Home ___ Office ___ Cell ___ Telephone ___ Fax ___ Email ___

 

Year of Graduation: __________________

 

Medical/Dental College in India/USA/Other: __________________________________________________

 

Private Practice: __________        Employed _______ Student _______ Resident _______ Retired _______

 

Spouse’s Name: ______________________ Children’s Names: ___________________________________

 

Would you like to be involved in any of the following committees of IMANE?

 

Community Service ___ Membership ___ Fundraising/Charity Gala ___ Scientific/CME ___ Other _______

 

Membership Dues

Life: $600    Life Couple: $1000    Active: $75    Active Couple: $120    YPS: $50

Associate(Resident): $25    Allied: $25    Student: Free

 Total Amount of Check: $ ______________

 

 

Please mail your application & check made payable to IMANE to:

Indian Medical Association of New England

P.O. Box 9132

Waltham, MA  02454-9132

Questions may be directed to the IMANE Chapter Administrator, Lynda Layer, at 781-434-7317 or llayer@mms.org.

ALL CONTRIBUTIONS TO IMANE ARE TAX DEDUCTIBLE