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AZERBAIJAN MEDICAL ASSOCIATION
11 R.Akhundov str , Baku , Azerbaijan 370007 ,
Tel: 99412 - 416479 , Fax: 99412 - 315136 ,
Email: azer.ma@medmail.com
, Website: www.azma.aznet.org
MEMBERSHIP APPLICATION FORM
Note: “Please click
on “File” and then on “Print” then fill out the form and return to
the AzMA office
PERSONAL DETAILS
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Name:________________________________________________________________
Last
First
Patronimic
Sex:_________________________
Marital Status _______________________________
( Male /
Female)
single /married /divorced
Title:
________________________________________________________________
Medical Student / Intern / Resident / Medical
practitioner /Prof.
Scientific
degree_______________________________________________________
Date of Birth_____________________ Place of Birth:
________________________
Day / month /
year
city / country
Work Address:
________________________________________________________
Tel: _______________________ Fax: _________________ Postal Code:
_________
Home Address:
________________________________________________________
Tel: ____________________ Fax: _________________ Postal Code:
____________
Pager: ___________________ Cell: _____________________ Email:
____________
Preferred Postal Add:
___________________________________________________
Passport No.:_______________________ |
PROFESSIONAL QUALIFICATIONS
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Basic Qualification: _________________ Country of Graduation:
_______________
Medical School/ University: _____________________ Year of
Graduation: _______
Postgraduate Qualifications:
_____________________________________________
(please state country and year of qualification)
____________________________________________________________________
Specialty:
____________________________________________________________
Area of Practice:
______________________________________________________
Private Practice / GP Government (Hospitals) / Military / Academic
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I confirm that the facts and details
provided are true and accurate to the best of my knowledge. As a member of
AzMA, I agree to be bound by the AzMA Constitution at all times.
Applicant’s
Signature: _____________ Date:
________/_________/________
ANNUAL SUBSCIPTION FEES FOR
YEAR 2001
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MEMBERSHIP CATEGORY
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MONTHLY
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FULL YEAR |
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PHYSICIAN |
3000 manat |
36000 manat |
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MEDICAL STUDENT |
1000 manat |
12000 manat |
I agree to pay the
subscription and to conduct myself professionally according to theCode of
Medical Ethics and be governed by the Constitution and Bylaws of the
Azerbaijan Medical Association
____________________________
________/_________/_______
Applicant’s Signature
Date
Any
member joining AzMA during the second half of the Financial Year (1 July
onwards) shall pay only half the annual subscription in respect of that
year.
The following part of the application form
will be completed by responsible person from the association
This applicant was elected
into full Membership to the
Azerbaijan Medical Association on
_____________________________
__________________________________
Date
Chief of the Membership Committee
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For Office Use Only
AzMA
Date
Rec’d:_____________Billed:________________
Rate Code: _____________Date Paid
:_____________
Membership code
number_____________________ |
Return To: 11
R.Akhundov str , 370007Baku , Azerbaijan Republic
For any questions please
contact:Tel: 99412-416479Email: azmamembership@medmail.com
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