Please complete each section of the AMDA Membership Application in it's entirety. 
Review and select the appropriate membership category.
I. General Information
Were you ever a member of AMDA? 
If yes, during what time period?
Member ID:
Prefix First Name M.I. Last Name Suffix
* *
Credentials
Credentials 2
Credentials 3
Title:
Company:
Office Phone #: * Inc In Directory?
Fax #: Inc In Directory?
Email: * Inc In Directory?
Web Site: Inc In Directory?
Home Phone:
Cell Phone:
Preferred Method of Communication:
Primary Address: Home  Business 
Street Address: *
Apt.#
City/State/Zip: * *
Country:
Secondary Address: Home  Business 
Street Address:
Apt.#:
City/State/Zip:
Country:
How did you learn about AMDA? Please list name of person, publication, campaign:
Nursing Home Information:
New: Medical Director at:
New: Attending Physician at:
II. Specialty
Primary Specialty:
Secondary Specialty:
Sub Specialty:
III. Check All That Apply
I serve as:
Medical Director   Attending Physician
Nurse Practicioner   Director of Nursing
Resident   Consultant Pharmacist
Adminstrator  
Other 
IV. Additional Information
AMDA Individual Extra
Bio:
V. AMDA offers the following membership categories. Please select one.
Category: *
Amount:
VI. State Chapters.
Payment of state chapter dues is collected by AMDA for the following states:
 Colorado Medical Directors Association
 Massachusetts State Chapter
 Michigan State Chapter
 Oklahoma State Chapter
 Oregon State Chapter
 No Chapter
VII. AMDA Foundation.
AMDA supports the AMDA Foundation by contributing $1.00 from your dues to support the Foundation’s dual mission to educate, mentor and inspire current and future long term care professionals and to advance quality and improve care through long term care research. Additional donations to this autonomous 501(c)(3) corporation are welcomed (see below). Your donation is tax deductible. To learn more visit www.amdafoundation.org.
 Check here if you DO NOT want $1.00 to be contributed to the AMDA Foundation.
VIII. Summary.
Contribution to AMDA Foundation: $
AMDA Membership Dues: $
State Chapter Membership Dues: $
Total Due: $
* = Required Field
  11000 Broken Land Parkway, Suite 400 Columbia, MD 21044
  Phone: (410) 740-9743 - Toll free: (800) 876-2632
  Fax: (410) 740-4572 - E-mail: webmaster@amda.com