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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.
Full-year membership includes 12 issues (Jan-Dec) of Menopause; Half-year membership
includes 6 issues (Jul-Dec) of Menopause
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:
Please provide the following information, allowing NAMS to serve the needs of its
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
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
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:
Please indicate if you would like your name to be added to the NAMS Website "Find
a Menopause Practitioner" list: (view the list here)
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?
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)
I would like to make this donation
in honor of
in memory of
(enter name as you would like it to appear on the NAMS Web site)
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