Online Membership Application Form

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Membership is open to to all Physicians, Dentists and other medical personnel associated with and interested in medical practices and the welfare of Liberia and Liberians including, but not limited to nurses, anesthetists, physicians assistants, respiratory technologists.

Please take a few minutes to fill out the below form and click the submit at the very end of the form when done. Sections with asterisks are required.

Dues:$250.00/yr for physicians in clinical practice
$100.00/yr for all other categories

First Name *

Last Name *

Phone number *

E-mail *

Mailing Address

City *

State/Country *

Zip code *

I am a *

Physician

Nurse

Physician Assistant

Other(specify in box below)

Required

If "other" above please specify

Medical School/School attended

Address of school attended

Year graduated

Postgraduate training(include institution)

Specialty

Which committee(s) are you interested in joining?

Academic Committee

Membership Committee

Fundraising Committee

Other:

Clear selection

Membership Dues Payment

Below are options for dues payment. Please check an option, submit the form and then pay by chosen option.

CashApp - $LMAUSA

PayPal: LMAUSA PayPal

Zelle: Recipient: Liberian Medical Association, Method: by email: payments@lmausa-inc.org

Required

Submit

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