AUXILIARY TO THE NATIONAL MEDICAL ASSOCIATION, INC
FOUNDER: MRS. ALMA WELLS GIVENS
MEMBERSHIP APPLICATION

Print out Membership Form - Click Here

Print out Individual Membership Dues Statement- Click Here

Sample Membership Form

[Check One] Mr ( ) Mrs. ( ) Dr.( )

NAME: ______________________________________________________________________________

ADDRESS: ________________________________________________________________

PHONE NO.: _________________________FAX NO.:_____________________

EMAIL: ___________________________________________________________

BUSINESS ADDRESS: __________________________________________________

LOCAL AUXILIARY AFFILIATION: ___________________________________ REGION:_______________________________

STATE AUXILIARY AFFILIATION: ___________________________________________________________________________

SPOUSE CONSTITUENT & COMPONENT SOCIETY: _______________________________________________________

SPECIAL SKILLS/INTERESTS: _______________________________________________________________________
___________________________________________________________________________________________________
_____________________________________________________________________________________________________

I hereby apply for membership on the Auxiliary to the National Medical Association, Inc. and do hereby agree to
abide by the laws governing this organization.

SIGNATURE: ________________________________________________________
DATE: _____________________________

( ) DUES CHECK ENCLOSED: AMOUNT $____________________________ CHECK NO. ____________________________
Please make check payable to ANMA, Inc.

( ) VISA ( ) MASTERCARD
If paying by credit card, please check Visa or MasterCard.

CREDIT CARD NO. ___________________________________EXP DATE: ______________________

NAME AS IT APPEARS ON THE CARD: __________________________________________________

SIGNATURE: __________________________________________________________________________

Please mail all forms and fees to:

Mrs. Laura H. Tompkins, Financial Secretary
1805 Gayfields Drive
Silver Spring, Maryland 20906
(301) 598-5211

Thank you for joining the Auxiliary to the National Medical Association, Inc.

Sample Individual Membership Dues Statement

NAME : _________________________________________________________________________________________
(LAST FIRST MI SPOUSE)

STREET ADDRESS:___________________________________________________________________

CITY, STATE, ZIP:____________________________________________________________________

PHONE NUMBER: ___________________________ EMAIL:__________________________________

AUXILIARY__________________________________ REGION:________________________________

LOCAL OR STATE PRESIDENT: ________________________________________________________

I certify that I am a financial member in good standing with my local and state auxiliary where one exists.

____________________________________________
SIGNATURE

ANMA Life Members are exempt from paying dues, but pay convention registration fees. Check here if ANMA Life Member ( )
MEMBERSHIP FEES

Postmarked on or before February 1st
Regular Member Dues $100.00 ______________________
Resident/Interns Spouse Dues $50.00 ______________________
Physician/Physician Dues $50.00 ______________________

Postmarked after February 1st
Regular Member Dues $125.00 ______________________
Resident/Interns Spouse Dues $60.00 ______________________
Physician/Physician Dues $60.00 _______________________

CONVENTION REGISTRATION FEES

Postmarked on or before May 30th
All Members $75.00 ______________________

Postmarked after May 30th
All Members $125.00 ______________________

Guest Registration $175.00 ______________________

ALMA WELLS GIVENS SCHOLARSHIP FUND
A 'TAX DEDUCTIBLE DONATION' is always appreciated and needed. Please check the appropriate donation category, and enclose the payment with your dues.
$25 ( ) $50 ( ) $75 ( ) $100+ ( )

Check# ____________________ Date: ________________
Total Enclosed $______________________

Please make checks payable to ANMA, Inc

If paying by credit card, please check Visa or MasterCard
( ) VISA ( ) MASTERCARD

Credit Card No. __________________________________________ Exp Date ____________________

Anti Fraud ID Code Backside of Card ____________________________

Name as it appears on the Card:_________________________________________________________

Signature:_______________________________________________

Please mail all forms and fees to:
Laura H. Tompkins, Financial Secretary
1805 Gayfields Drive Silver Spring, MD 20906-1220
(301) 598-5211