HAMAH ::: Hispanic American Medical Association of Houston

Hispanic American Medical Association of Houston

Membership Application

First Name (*)

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Middle Initial

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Last Name (*)

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Degree (s):

. . MD. . . . . Do. . . . . PhD. . . . . FACR. . . . . Other. . .

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Contact Information: (Please provide both work and office info and check preference contact)

Home Address:

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Phone:

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Fax:

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Email: (*)

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Office Address:

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Phone:

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Fax:

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Email: (*)

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Country of Origin:

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Medical School:

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Year Graduated:

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Residency:

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Start mm.dd.yyyy:

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Finish mm.dd.yyyy

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Board Certification:

. . Yes . . No

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Type of Certificate:

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Date mm.dd.yyyy:

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Specialty: Indicate primary specialty for directory listing:

. . Anesthesiology
. . Cardiology
. . Diagnostic
. . Emergency
. . Department
. . General
. . Head & Neck
. . Neurology
. . OB/GYN
. . Pediatrics
. . Orthopedic
. . Primary Care
. . Surgeon

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Are you a member of a group practice?

YesNo

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Name of Group:

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City, State:

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Membership Annual Dues

(please check appropriate box)

. . Active Members (In Practice) $100.00
. . Associate Member (Non-Hispanic physician, In practice) $100.00
. . Member-in-Training (Resident and Fellow) $50.00
. . Emeritus(previously active but no longer practicing) $25.00
. . Medical Student FREE!

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Dues Enclosed:

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-Please make your check payable to HAMAH

- Sorry for the inconvenience at this time we are only accepting checks. Thank You!

Please send completed form and payment to:

Hispanic American Medical Association of Houston  HAMAH

11929 W. Airport Blvd., Oasis Tower One, Suite 600, Stafford, TX 77477

Phone: 281-494-2644 832-287-3439
Fax: 281-494-2650
Email: dgcorredor@gmail.com

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