Minority Affairs Consortium Membership Form

*Name:
 

Mailing Address: 
Home
Office

*Address:

*City:

*State:
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*Zip code:

*Phone:

Fax:

E-mail will be the primary vehicle for Consortium communications.
Your e-mail address will not be shared, sold, traded, exchanged or rented. See our Privacy Policy.

Do you have e-mail access? 
Yes
No

*Preferred e-mail address:

Secondary e-mail address:


Category:
MD
DO
Medical Student

Gender: 
Female
Male

Race:
 Black/African-American
Hispanic/Latino
Asian
White
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Other, please specify
 
I do not wish to designate a race/ethnicity.

AMA member: 
Yes
No

AMA Medical Education Number:

Special interests:
 

Other Comments:

Minority Affairs Consortium
American Medical Association
515 N. State Street
Chicago, IL 60654
Fax: (312) 464-5845