CBMANA | Central Bangladesh Medical Association of North America

Central BMANA Membership

Membership

Personal

Address

Professional

Position

Declaration

Signature

Select Membership Type

Life Membership

One-time payment, lifetime benefits

$300

Active Membership

Annual subscription with renewal

1 Year

$50

2 Years

$100

Personal Information

First Name

Last Name

Email Address

Cell Phone

Home Phone

Office Phone

Address Information

Home Address

Office Address

Preferred Mailing Address

Home Address Office Address

Professional Information

Specialty

Medical School

Graduation Year

State of Licensure

License Number

Hospital Affiliation

Current Professional Position

Select all positions that currently apply to you

Practicing Medicine in America

Active clinical practice

Not Practicing in North America

Currently not in clinical practice

PhD

Doctor of Philosophy degree

Research Position

Active in medical research

Academic Position

Faculty or teaching role

Retired

From active practice

Other Position (Optional)

Declaration & Agreement

Accuracy of Information

I certify that all information provided in this application is accurate and complete.

Information Disclosure

I agree to disclose this information for BMANA membership registry and publication.

Communication Consent

I consent to receive communications from CBMANA regarding events and updates.

Signature & Date

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Date

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