Affiliate Membership
 You may print this form and fill it out offline or fill it out online, print it and FAX it to us at 562 799-3355  or mail it to 1945 Palo Verde Ave. Suite 202, Long Beach, CA 90815-3445. 

If you prefer to complete the application process online, use the "Submit" button at the bottom of this page

Name  
Profession

Title
Organization
Address
Address 2
City
State/Province
Zip code
Phone
FAX
E-mail Mandatory for Internet ready discount
URL
Zip/Postal code
Country (if not USA)
 Date of birth  Male    Female
Additional information:

By submitting this form, I attest that all of the information in this application is accurate and truthful.  
I understand that willful falsification or failure to disclose pertinent information constitutes grounds 
for denial or subsequent forfeiture of membership and Diplomate status.  Submission of this form 
authorizes the Academy of Managed Care Providers to verify information provided in this application.

Please provide the following billing information:

Credit card
Amount Authorized
Cardholder name
Card number
Expiration date