AIIMSONIANS OF AMERICA - MEMBERSHIP FORM
First Name _____________________ Last Name ______________________
Middle Initial _____________________
Date of Birth _____ / _____ / _____
Home Address:
Street ______________________________________________________
City ______________________________________________________
State ______________________________________________________
Zip _______________________
Work Address:
Street ______________________________________________________
City ______________________________________________________
State ______________________________________________________
Zip _______________________
Family:
Spouse ____________________________________________________________
Aiimsonian ? Yes |
No
If yes, Year of Entry ________________________
Children ___________________________________________________________
Preferred Communication ? Home | Work (please tick)
Home Phone ________________________________________________________
Work Phone ________________________________________________________
Home Fax __________________________________________________________
Work Fax __________________________________________________________
Email ____________________________________________________
Mobile ____________________________________________________
Pager ____________________________________________________
Year of entry to AIIMS ____________________________________________
AIIMS Degree / Degrees _______________________________________________
Specialty _________________________________________________
Roll Number ______________________________________________
Membership fees enclosed:
Annual $50.00 ______________
Life (one time fees) $750.00 _______________
(Aiimsonian spouse $500). If your spouse is also an
Aiimsonian, please use a copy of this form for her/him.
Annual (for Resident/Fellows) $25.00 ___________
Please Mail to:
Anil Batra, MD
c/o AOA
3650 South Eastern Avenue # 230
Las Vegas, NV 89109
|
Membership Application 
