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Membership Registration

Credit Card Billing Address: must match your credit card (used for verification)

Last Name:   First Name:  
Middle Initial:
Credentials:
Address 1:  
Address 2:
City:  
Country:  
State/Province:
 
Zip/Postal Code:  
Telephone: Fax:
Email Address:  

Applicant's Address: if different from billing address (items from NAMS will be mailed to this address)

Same As Above
Last Name:   First Name:  
Middle Initial:
Credentials:
Address 1:  
Address 2:
City:  
Country:  
State/Province:
 
Zip/Postal Code:  
Telephone: Fax:
Email Address:

An application confirmations will be sent to the address above from namssite@menopauseemail.org. Please make sure to white-list this address so your confirmation doesn't go to your junk folder or spam filter.

Please check the box to verify you have read the following statement.  

If elected to membership, I agree to support the mission and to further the efforts of the Society. I have completed the second page of this form, and have enclosed payment of annual dues for the membership category indicated below.


Membership Payment




 

Full-year membership includes 12 issues (Jan-Dec) of Menopause; Half-year membership includes 6 issues (Jul-Dec) of Menopause

*For Associate Member Applicants Only

I certify that I am qualified for Associate Member status by being a student, resident, or fellow in a formal training program on the following date:  

Please provide the name of an authorized representative that can verify your scholastic program (such as professor or director of residency or fellowship program).

Authorized Representative's Name:   

Additional Information Requested

Please provide the following information, allowing NAMS to serve the needs of its members.

Profession














 

Are you primarily involved in:



 

Specialty




















 

e-Subscriptions

If you are not already receiving these broadcast email alerts from NAMS and would like to, check the appropriate "yes" box.

General NAMS news and notices

First to Know® e-newsletter

Menopause Care Updates e-newsletter

Menopause e-Consult® e-newsletter


Please complete the following:

1. Do you have a valid and unrestricted license for clinical practice?

 

2. Do you have a valid and unrestricted DEA Registration Number?

 

3. Have you ever been denied membership or reappointment to the medical staff of any hospital or have your privileges ever been suspended, curtailed, or revoked?

 

4. Have you ever been: (i) convicted of healthcare fraud or a healthcare-related crime; (ii) suspended, sanctioned, restricted, or excluded from participating in any private, federal, or state health insurance program;(iv) convicted of any crime in the course and scope of your professional employment?

 

5. Have any adverse circumstances occurred that prevent you from obtaining malpractice insurance?

 

6. Have you ever been convicted of a felony?

 

If you answered "No" to questions 1 or "Yes" to any questions 3-6, please explain:


Find A Menopause Practitioner

Please indicate if you would like your name to be added to the NAMS Website "Find a Menopause Practitioner" list: (view the list here)


 
Office Address 1:
Office Address 2:
City:
Country
Office Telephone
State
Zip

Promotional Mailings

NAMS occasionally rents the names and postal addresses of its members to third parties for promotional mailings with contents approved by NAMS Board of Trustees. Do you wish to receive these mailings?

 

Donation

Gifts of all sizes are appreciated. NAMS will respond with a letter documenting your tax-deductible donation.

Please designate my donation to:

(enter a dollar amount without using a dollar sign or comma)

Education & Research Fund (ERF)
Unrestricted
Thomas B. Clarkson Outstanding Clinical & Basic Science Research Award
Leon Speroff Outstanding Educator Award
Ann Voda Community Service Award
Irwin J. Kerber Membership Scholarship Endowment
______________________
Total Gift Amount

I would like to make this donation (enter name as you would like it to appear on the NAMS Web site)


Payment Information

Name On Credit Card:  
Payment Card Type:  
Payment Card Number:  
Payment Card Expiration Date: /    
Payment CVT:  

Submit your Application

When you submit your online membership form, the server will encrypt your information and transmit it directly to the bank for processing. NAMS does not receive your personal account information.

A NAMS customer support representative will contact you if additional information is required.



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