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2024 Membership Application
Membership is based on Calendar year from Jan through Dec.
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* Indicates required question
Email
*
Your email
Are you currently receiving emails from the Association?
*
Yes
No
First Name:
*
Your answer
Middle Name:
Your answer
Last Name:
*
Your answer
Professional Designation:
*
MD
DO
DMD
DDS
PharmD
OD
PA-C
ARNP
DC
Other:
State License Number
*
Your answer
Specialty:
*
Your answer
Mailing Address:
*
Your answer
Phone number:
*
Your answer
Membership Dues
*
$85 One Year Membership
$210 Three Year Membership
Method of Payment
*
Paid Wave Invoice
Paypal online:
https://vampgroup.org/payment
Zelle (zelle to
vampgroupfl@gmail.com
). Add
vampgroupfl@gmail.com
to your contacts first.
Check payable to “ Vietnamese American Medical Professionals" and mail to : Son Ho, MD 2098 Osprey Avenue Orlando FL 32814
A copy of your responses will be emailed to the address you provided.
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