Membership Registration

How did you first learn about SNMA:
Region:
Chapter ID:	[ ]
Salutation:
First Name * :
Middle Initial:
Last Name * :
Suffix:
Gender:
Marital Status:
Birthday:	(format: yyyy-mm-dd)
Race:
Title:
College ID:	[ ]
Graduation Year:	(numbers only)
Current Degree:
Expected Degree:
Classification:
Location Information
Address1 * :
Address2:
City * :
State * :
Zipcode * :
Country * :
Contact Information
Phone * :
Phone2:
Mobile Phone:
Fax:
Email Address * :
Membership Information
Active (med. student), 4 years - $100
Active (med. student), 1 year (only after initial 4-year) - $30
Associate, 1 year - $25
Associate, 2 year - $35
Physician/Patron, 1 year - $50
Institution, 1 year - $250
Corporate, 1 year - $500
Life Member (Active/Associate) - $300
Life Member (Physician/Patron) - $600
Word Verification * :
I hereby apply for membership in the Student National Medical Association and understand that I am eligible to continue my membership as long as I remain within the guidelines of the SNMA Constitution and By-Laws. I am submitting the appropriate and required membership dues along with this application to the address shown below. I Accept the terms