The Burmese Medical Association of North America

Connecting Burmese Medical Professionals Across the United States and Canada

Membership Application

 

Title:   please circle one: Male Female
First Name: DOB (mm/dd/yyyy):___/___/______

 
Middle Name(s):  
Last Name:  

 
Year Graduated:  
Degree Conferred:  
Specialty:  
Address:  

 
City:  
State, Zip/Postal Code:  
Country:  
Telephone #1:   Ext:  
Telephone #2:   Ext:  
Fax:  
E-mail:  

 


Please send this completed form along with check or money order to:
                                                   
$100Physicians and Doctors                                                Sein Aung, M.D.
$25Residents and Retirees Treasurer, BMANA
$50Non-Physicians P.O. Box 20052
freeIn-Transition Baltimore, MD 21284

 

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http://www.bma-na.net/