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Membership Application for the Association of Minority Nephrologists
Please complete and update all information Missing fields can delay your membership
First Name
Last Name
Suffix
Degree(s)
Title
Institution
Department/Division
Address
City
State
Zip Code
Country
Phone Number
Fax Number
Email Address
EDUCATION
Medical School
Year Graduated
Post Graduate Training
Undergraduate/Professional School
Trained Specialty
Years of Practice
Type of Practice
PAYMENT INFORMATION
Type of check: Personal Business University Bill Me
	$50.00 annual membership for Physicians
	$50.00 annual membership for Associated non-health professionals
	$25.00 annual membership for Nurses/allied health professional
	No annual membership fee for Fellows and Medical Students
We are currently accepting payments through the mail only. Please print this form and mail along with your payment to: Association of Minority Nephrologists 11705 Deputy Yamamoto Pl Suite B Lynwood , CA 90262 Telephone: (323) 249-5704 Fax: (323)357-3795 Email: info@aomn.org

Membership Application for the Association of Minority Nephrologists