2024 Membership Auto Renewal NAAMA 2024 Membership Form Valid Jan 1-Dec 31/2024.Membership(Required) New Member Old Member Student: Premed, Medical, Residency Please choose oneSTOP! Student: Premed, Medical, Residency: please visit naamanextgen.com to become a member. About YouSalution(Required)Dr.Mr.Mrs.Ms.Click to choose from a listYour Name(Required) First Last Specialty(Required) Your Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How Can We Reach You?We would love to chat with you. How can we get in touch?Your Email Address(Required) Cell Phone(Required)MembershipI am a member of : Please choose one(Required) Georgia Chapter Houston, Texas Chapter Illinois Chapter LA, California Chapter Michigan Chapter New Jersey Chapter San Diego, California Chapter St. Louis, Missouri Chapter No Chapter in My Area Membership Fee(Required) ACTIVE (MEDICAL DOCTOR / DENTISTRY / PHARMACY / SCIENTIST) - With Chapter Fee $300 ACTIVE (NURSING / ALLIED HEALTH PHYSICIAN ASSISTANT, PUBLIC AND MENTAL HEALTH PROFESSIONAL) - With Chapter Fee $250 AUXILIARY - SPOUSE / FRIEND OF NAAMA - With Chapter Fee $150 RETIRED - With Chapter Fee $150 Lifetime Membership - Fee $6000 Membership without Chapter Fee(Required) ACTIVE (MEDICAL DOCTOR / DENTISTRY / PHARMACY / SCIENTIST) - No Chapter in My Area $225 ACTIVE (NURSING / ALLIED HEALTH PHYSICIAN ASSISTANT, PUBLIC AND MENTAL HEALTH PROFESSIONAL) - No Chapter in My Area $175 AUXILIARY - SPOUSE / FRIEND OF NAAMA No Chapter in My Area $75 RETIRED - No Chapter in My Area $75 Lifetime Membership - Fee $6000 Total Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name auto renewal HiddenNext Steps: Install a Payment Add-OnTo accept donations via this form you will need to install one of our payment add-ons. To learn more about your payment add-on options, visit the following page (https://www.gravityforms.com/blog/payment-add-ons). Important: Delete this tip before you publish the form.Name(Required) First Last Email(Required) Enter Email Confirm Email Donation Amount(Required) 10 USD 50 USD 250 USD Other amount Choose how much you would like to donate.Other Amount Total HiddenCredit CardReplace this field with a field specific to your payment gateway whenever possible.Credit Card DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name