AMA membership application form

Name:                                                       Title:                                   

Institution:                                                                                             

Street:                                                                                                     

City:                                                    State:                Zip:                     

Phone:                                        FAX:                                                      

email:                                             Web site:                                           

Individual dues     Organizational dues

Student/ Retired $5.00       Annual budget less than $50,000 - $25.00 (may send two reps to any AMA function)

Individual $10.00                Annual budget $50,000 to $100,000 - $50 (may send four reps to any AMA function)

Contributing $25.00           Annual budget over $100,000 - $100.00 (may send eight members to any AMA function)

Print this form, fill out the information, circle the dues amount you are paying and mail to:

AMA

c/o The AR NG Museum

Camp Robinson

North Little Rock, AR 72199-9600

Make checks payable to AMA